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 C
Explanation
Irrigating the tube with 30 mL of sterile saline as needed. This prescription should be questioned by the nurse because it may cause trauma to the kidney or dislodge the tube. The nurse should only irrigate the tube if ordered by the health care provider and with a smaller amount of fluid.
Choice A is wrong because monitoring the urine’s color and odor is an appropriate intervention for a client with a nephrostomy tube. The urine may be bloody or cloudy initially, but it should gradually clear.
Choice B is wrong because recording the intake and output every eight hours is also an appropriate intervention for a client with a nephrostomy tube. The nurse should measure and document the amount and characteristics of urine drainage and report any changes or abnormalities.
Choice D is wrong because measuring the vital signs every four hours during the day is a reasonable prescription for a client with a nephrostomy tube. The nurse should monitor the client for signs of infection, bleeding, or obstruction.
Correct Answer is C
Explanation
This is because renal calculi can cause renal colic, which is a sudden and intense pain in the flank area that radiates to the groin or testicles.
The pain is caused by the stone obstructing the ureter and triggering spasms.
Choice A is wrong because a feeling of pressure in the bladder is more likely to indicate a lower urinary tract infection or an overactive bladder.
Choice B is wrong because a mild, burning pain when urinating is more likely to indicate a urinary tract infection or a urethral injury.
Choice D is wrong because a constant, dull, aching pain in the right upper quadrant is more likely to indicate a liver or gallbladder problem.
Normal ranges for urine pH are 4.5 to 8.0, and for specific gravity are 1.005 to 1.030.
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