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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
“I can’t promise that the information won’t be shared if your health or safety is involved.” This response by the nurse would be appropriate because it respects the client’s confidentiality while also acknowledging its limits of it. The nurse has a duty to report any information that may indicate a risk of harm to the client or others.
Choice A is wrong because it dismisses the client’s need to share something and implies that the nurse is not interested or trustworthy.
Choice B is wrong because it gives a false assurance of confidentiality and may lead to ethical dilemmas if the client reveals something that requires reporting.
Choice C is wrong because it does not address the issue of confidentiality and may give the impression that the nurse is trying to avoid the conversation.
Correct Answer is B
Explanation
To find the rate of the pump in ml/hour, you need to first convert the client’s weight from pounds to kilograms. You can do this by dividing the weight by 2.2046 or multiplying it by 0.454.
For example:
297 lbs / 2.2046 = 134.72 kg or 297 lbs x 0.454 = 134.72 kg
Then, you need to multiply the client’s weight in kilograms by the ordered dose in units/kg/hour to get the total units per hour.
For example:
134.72 kg x 12 units/kg/hour = 1616.64 units/hour
Next, you need to set up a proportion to find the rate of the pump in ml/hour using the supplied medication concentration.
For example:
25,000 units / 500 ml = 1616.64 units / X ml Cross-multiply and solve for X:
25,000 x X = 808320 X = 808320 / 25000 X = 32.33 ml/hour
Finally, you need to round your answer to the nearest tenth of a ml/hour as per the medication administration guidelines.
For example:
32.33 ml/hour ≈ 32.3 ml/hour
Therefore, the rate of the pump is 32.3 ml/hour.
Choice A is wrong because it uses a different conversion factor for pounds to kilograms (1 lb = 0.5 kg) which is not accurate.
Choice C is wrong because it uses a different ordered dose (10 units/kg/hour) which is not what the provider has written.
Choice D is wrong because it uses a different supplied medication concentration (20,000 units in 500 ml) which is not what is available.
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