A nurse is assisting with the care of a client.
The nurse is reinforcing teaching for the client and their family about potential adverse effects of the client's prescribed medications.
For each potential adverse effect, click to specify if the effect is. consistent with agranulocytosis, neuroleptic malignant syndrome, or. serotonin syndrome.
Each finding may support more than 1 disease process.
Sore throat
Disorientation
Blood pressure changes
Tachycardia
High fever
Agranulocytosis
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B,C"},"C":{"answers":"B,C"},"D":{"answers":"B,C"},"E":{"answers":"B,C"},"F":{"answers":"A"}}
|
Condition |
Definition |
Causes |
Symptoms |
Treatment |
|
Agranulocytosis |
A severe and potentially life-threatening reduction in the number of white blood cells (neutrophils) that fight infection. |
Can be caused by some antipsychotic medications, such as clozapine, olanzapine, and quetiapine. |
Sore throat, fever, chills, mouth ulcers, infections, bleeding, and fatigue. |
Discontinuation of the offending medication, antibiotics, antifungals, and granulocyte colony-stimulating factor (G-CSF) injections to stimulate the bone marrow to produce more white blood cells. |
|
Neuroleptic Malignant Syndrome (NMS) |
A rare but serious reaction to antipsychotic medications, especially the older ones, such as haloperidol, fluphenazine, and chlorpromazine. |
Can be triggered by high doses, rapid dose changes, or switching of antipsychotic medications. |
High fever, muscle rigidity, altered mental status, autonomic instability (blood pressure changes, tachycardia, sweating, etc.), and elevated creatine kinase levels. |
Discontinuation of the offending medication, supportive care, cooling measures, hydration, and medications such as dantrolene, bromocriptine, or amantadine to counteract the effects of dopamine blockade. |
|
Serotonin Syndrome |
A potentially life-threatening condition caused by excessive levels of serotonin in the brain. |
Can be caused by taking too much of a serotonin-enhancing medication, such as selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), or other drugs that affect serotonin levels, such as tramadol, linezolid, or St. John’s wort. Can also be caused by combining two or more serotonin-enhancing medications. |
Agitation, confusion, disorientation, anxiety, hallucinations, muscle spasms, tremors, shivering, hyperreflexia, incoordination, diarrhea, nausea, vomiting, blood pressure changes, tachycardia, and hyperthermia. |
Discontinuation of the offending medication(s), supportive care, hydration, and medications such as benzodiazepines, cyproheptadine, or serotonin antagonists to reduce serotonin levels. |
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is a. Plan to remove the restraints as soon as the client is calm.
Choice A reason: The primary goal after applying restraints is to ensure the safety of the client and others. Once the client is calm, planning for the removal of restraints is essential to maintain the client’s dignity and to adhere to ethical standards of minimizing restraint use.
Choice B reason: While offering snacks is part of general care, it is not specifically related to the immediate action required following the application of restraints. Nutritional needs should be addressed, but they do not take precedence over the assessment and potential removal of restraints.
Choice C reason: Ensuring that a prescription for restraints is signed within 48 hours is a legal requirement, but it is not the immediate action to be taken following the application of restraints. The focus should be on the client’s current state and reassessing the need for continued restraint.
Choice D reason: Monitoring the client’s range of motion every 60 minutes is important to prevent complications from restraint, such as contractures or muscle atrophy. However, this is secondary to the immediate reassessment of the need for restraint and planning for its removal as soon as the client is calm.
Correct Answer is C
Explanation
Choice A rationale:
Offering toileting opportunities every 1 to 2 hours is a valid intervention in a bladder training program. However, it should not be the first action. Before establishing a toileting schedule, the nurse should assess the client's current voiding patterns to determine the most appropriate schedule based on the client's needs.
Choice B rationale:
Assisting the client with relaxation techniques can be beneficial in managing urinary incontinence or frequency, but it should not be the first action. Understanding the client's voiding pattern and any factors contributing to their urinary issues is essential before implementing relaxation techniques.
Choice C rationale:
Determining the client's pattern for voiding is the first step in developing a tailored bladder training program. This assessment helps identify the client's specific needs and enables the nurse to create a personalized plan that addresses their issues effectively.
Choice D rationale:
Discouraging intake of carbonated beverages is a valid intervention in managing urinary incontinence or frequency, but it should not be the first action. It's important to assess the client's individual habits and patterns before making dietary recommendations.
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