A nurse is caring for a client in the outpatient mental health clinic

exhibits

Click to highlight the findings that indicate the client is experiencing adverse effects of the medication. To deselect a finding, click on the finding again
Nurses' Notes
Today

Client states "I’m feeling much better." They report less fatigue even though they have difficulty sleeping. Client reports they are not sad anymore but are experiencing more frequent headaches. Client continues to deny any suicidal ideation

Vital Signs
Today
BP 149/91 mm Hg

Heart rate 75min

Respiratory rate 18/min

difficulty sleeping

frequent headaches

feeling much better

less fatigue

Answer and Explanation

The Correct Answer is ["A","B"]

Client states "I’m feeling much better." They report less fatigue even though they have difficulty sleeping. Client reports they are not sad anymore but are experiencing more frequent headaches. Client continues to deny any suicidal ideation
Vital Signs
Today
BP 149/91 mm Hg

Heart rate 75min

Respiratory rate 18/min

Explanation:

Based on the provided information, the following findings indicate the client may be experiencing adverse effects of the medication (fluoxetine):

Increased headaches: The client reports experiencing more frequent headaches, which can be an adverse effect of fluoxetine.
Difficulty sleeping (hypersomnia): The client reports difficulty sleeping despite feeling less fatigued, which could be related to the medication's effect on sleep patterns.

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Free Nursing Study Resources

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"E"}

Explanation

Serotonin syndrome: This is a potentially life-threatening condition caused by an excess of serotonin in the brain. It can occur when there is an increase in the dose of an SSRI or when a new SSRI is introduced, particularly if the client has recently been on another SSRI, as in this case where fluoxetine was switched to paroxetine.

Selective serotonin reuptake inhibitors (SSRIs): Both fluoxetine and paroxetine are SSRIs. The risk of serotonin syndrome increases with changes or increases in the dosage of SSRIs due to the potential for excessive serotonin levels.

A. Clamp the catheter tubing for 30 min. B. Obtain a urine specimen for culture and sensitivity. C. Initiate continuous bladder irrigation. D. Administer a fluid bolus.

Correct Answer is D

Explanation

A. Incorrect. Clamping the catheter tubing might not be necessary in this situation and could potentially cause urinary retention.

B. Incorrect. While obtaining a urine specimen might be necessary if there's suspicion of infection, the immediate concern in this case is the low urine output rather than infection. Therefore, this may not be the first action taken.

C. Incorrect. Continuous bladder irrigation might be indicated for specific situations, such as after certain surgeries, but it is not the first-line intervention based solely on the description provided.

D. Incorrect. Administering a fluid bolus might not be necessary unless there are other signs of dehydration or fluid imbalance.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client at a clinic. Exhibits Complete the following sentence by using the lists of options. The client is at risk for developing dropdown due to dropdown.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"E"}

Explanation

A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate?

Correct Answer is D

Explanation

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