A client taking paroxetine (Paxil) presents to the emergency room with agitation, increased sweating, and new auditory hallucinations.
What is the priority action?

Ask if the patient has started any new prescription or over-the-counter medications.

Administer an anti-anxiety medication to subdue and sedate the patient.

Place the patient in loose bilateral arm restraints.

Tell the patient that the voices they are hearing are not real.

Answer and Explanation

The Correct Answer is A

This is because the patient may be experiencing serotonin toxicity, a potentially life- threatening condition caused by excessive levels of serotonin in the brain. Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) that increases serotonin levels, and some other medications or supplements may interact with it and cause serotonin toxicity. Some of the symptoms of serotonin toxicity include agitation, increased sweating, and hallucinations.

Choice B is wrong because administering an anti-anxiety medication may worsen serotonin toxicity, especially if the medication is also an SSRI or another serotonergic agent.

Choice C is wrong because placing the patient in loose bilateral arm restraints may increase the risk of injury or agitation, and does not address the underlying cause of the symptoms.

Choice D is wrong because telling the patient that the voices they are hearing are not real may not be helpful or reassuring, and may also increase the patient’s distress or confusion.

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Correct Answer is C

Explanation

This action would cause the nurse to intervene because it increases the risk of choking and aspiration for a client with dysphagia, which is difficulty swallowing. The nurse would instruct the UAP to feed the client small amounts of food slowly, allowing time for chewing and swallowing.

Choice A is wrong because offering thickened liquids is a safe practice for a client with dysphagia. Thickened liquids allow for easier swallowing and less choking, thus decreasing the chance of aspiration.

Choice B is wrong because placing the client in an upright position is also a safe practice for a client with dysphagia. This position helps prevent food from entering the airway and facilitates swallowing.

Choice D is wrong because allowing ample time between bites is another safe practice for a client with dysphagia. This helps the client avoid feeling rushed or overwhelmed and reduces the risk of aspiration.

A. “Only the client’s health care provider is authorized to release that information.”. B. “I can confirm that the client is on the unit but no diagnosis has been made.”. C. “I don’t know because tests are still being run on the client.”. D. “You need to speak to the designated hospital contact.”.

Correct Answer is D

Explanation

You need to speak to the designated hospital contact. This is because the nurse has a duty to protect the client’s privacy and confidentiality, and cannot disclose any information about the client’s diagnosis or condition to the reporter without the client’s consent.

The nurse should refer the reporter to the hospital’s public relations department or spokesperson, who is authorized to handle such inquiries.

Choice A is wrong because it implies that the client’s healthcare provider can release the information without the client’s consent, which is not true.

Choice B is wrong because it confirms that the client is on the unit, which is a violation of the client’s privacy.

Choice C is wrong because it gives false information about the client’s status, which is unethical and unprofessional.

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A client taking paroxetine (Paxil) presents to the emergency room with agitation, increased sweating, and new auditory hallucinations. What is the priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The unlicensed assistive personnel (UAP) is feeding a client with dysphagia. What action would cause the nurse to intervene?

Correct Answer is C

Explanation

A television reporter calls the nursing unit requesting an update on the status of an elected official from the community who was admitted to the unit. Which statement is the most appropriate response by the nurse when the reporter requests the official diagnosis?

Correct Answer is D

Explanation

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A client taking paroxetine (Paxil) presents to the emergency room with agitation, increased sweating, and new auditory hallucinations.
What is the priority action?