A nurse is assisting with the care for a newly admitted client who has major depressive disorder.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Exploring reasons for her behavior is important for understanding the underlying issues, but the immediate priority is to ensure the client's safety.
B. Providing strategies for redirecting violent behavior is a relevant intervention, but it is not the priority in this situation. Safety concerns related to self-harm take precedence.
C. Encouraging the client to talk about her feelings is a valuable therapeutic intervention, but in the context of borderline personality disorder, the immediate priority is to address the risk of self-harm. Once the client's safety is ensured, exploring feelings and developing coping strategies can be part of the ongoing therapeutic process.
D. Protecting the client from self-harm behavior is the priority because individuals with borderline personality disorder are at an increased risk of engaging in self-harming behaviors,
Correct Answer is C
Explanation
A. "Everyone has trouble sleeping at times" minimizes the client's concerns and may not address the underlying issues contributing to their anxiety.
B. "Why do you think you are so anxious?" might come across as judgmental or confrontational, and it may not create a supportive environment for the client to open up about their feelings.
C. "Have you talked to your provider about this yet?"
This response encourages the client to seek professional help and addresses the issue of increasing anxiety and difficulty sleeping. It is supportive and guides the client toward discussing their concerns with a healthcare provider who can assess the situation and provide appropriate interventions.
D. "It sounds like you're having a difficult time" acknowledges the client's distress but does not guide them toward seeking professional help. Encouraging a conversation with a healthcare provider is a more direct and helpful approach.
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