A nurse is assisting with the care for a newly admitted client who has major depressive disorder.

Exhibits

Select 1 condition and 1 client finding to fill in each blank in the following sentence (Separate using a comma).

The client is at risk for developing
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due to the Client's intake of
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Answer and Explanation

The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

The client is at risk for developing Serotonin syndrome due to the Client's intake of St. John's wort

Explanation:

St. John's wort is an herbal supplement that can interact with certain medications, including selective serotonin reuptake inhibitors (SSRIs) and other medications that increase serotonin levels. Serotonin syndrome is a potentially life-threatening condition characterized by an excess of serotonin in the body.

In the given scenario, the nurse should identify:

Condition: The client's intake of St. John's wort

Client Finding: At risk for developing serotonin syndrome

This is because the use of St. John's wort, combined with medications that affect serotonin levels, increases the risk of serotonin syndrome. The nurse should monitor for symptoms of serotonin syndrome, such as changes in vital signs, hyperthermia, altered mental status, and neuromuscular abnormalities. If serotonin syndrome is suspected, medical attention should be sought promptly.

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Correct Answer is C

Explanation

A. Planning with the client for how he can better handle frustration (option A) is a valuable intervention, but it may not be immediately effective in the midst of heightened agitation. It is better suited for a calmer, more reflective time.

B. Placing the client in a monitored seclusion room until he is calm (option B) is an option for managing extreme agitation, but it should be used cautiously and as a last resort. Offering medication and attempting verbal de-escalation are generally preferable initial steps.

C. Offer the client an antianxiety medication.
When dealing with a client who is agitated and potentially escalating to a more volatile state, offering an antianxiety medication can be a helpful and immediate intervention to manage acute distress. It can aid in calming the client down and create an environment where other therapeutic interventions can be more effectively implemented.

D. Restraining the client to prevent injury to himself or others (option D) is a highly invasive intervention and should only be considered when there is an imminent risk of harm to the client or others. It is generally not the first choice in managing agitation due to its potential negative impact on the therapeutic relationship and the client's well-being.

A. History of kidney disease B. When the client last drank alcohol C. If the client has taken disulfiram before D. History of liver disease

Correct Answer is D

Explanation

A. History of kidney disease is not as critical for disulfiram administration. The primary concern is related to hepatic metabolism.

B. When the client last drank alcohol is relevant information, but it is not the most critical factor to consider before administering disulfiram. The primary mechanism of disulfiram is to inhibit the breakdown of acetaldehyde, leading to an unpleasant reaction if alcohol is consumed, regardless of when the client last drank.

C. Whether the client has taken disulfiram before is important information, but it does not take precedence over the assessment of liver function. The history of liver disease is more directly related to the potential risks and adverse effects associated with disulfiram use.

D. History of liver disease is crucial to assess before administering disulfiram because disulfiram is metabolized in the liver. Patients with a history of liver disease may have impaired liver function, and the medication may not be well-tolerated or could exacerbate existing liver issues.

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Naxlex Comprehensive Predictor Exams

A nurse in a mental health facility is caring for a client who becomes upset and breaks a chair when a visitor does not arrive. The client remains agitated following initial verbal attempts to calm him down. Which of the following interventions should the nurse implement first?

Correct Answer is C

Explanation

A nurse is collecting data from a client admitted to an inpatient mental health unit and has a new prescription for disulfiram (Antabuse). Which of the following information is most important for the nurse to obtain before administering this medication?

Correct Answer is D

Explanation

A nurse is assisting with the court-ordered admission of a client to a substance-abuse program. The client states, "You are all angry at me and wish you could go out and have a drink." The client's response is an example of which of the following defense mechanisms?

A nurse is collecting data from a group of clients who have anxiety disorders and have prescriptions for various psychotropic medications. The nurse should recognize which of the following clients as having an increased risk for suicide?

A nurse is caring for a client who has been brought to the emergency department and is experiencing acute fentanyl toxicity. The nurse should expect to observe which of the following adverse effects in this client?

A nurse is caring for a client who witnessed her brother's homicide and has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect?

A nurse is reviewing the admission laboratory values for a client who has a history of bulimia nervosa. Which of the following findings is the nurse's priority?

A nurse in an acute care mental health facility is contributing to the plan of care for a client who is newly diagnosed with schizophrenia and is verbalizing paranoid delusions. Which of the following interventions should the nurse include in the plan?