A nurse is caring for a client who has generalized anxiety disorder and is taking buspirone. Which of the following adverse effects should the nurse report to the provider?

Sweating and fever

Discolored urine

Decreased appetite

Hallucinations.

Answer and Explanation

The Correct Answer is A

The adverse effect the nurse should report to the provider is A. Sweating and fever.

This combination of symptoms is a key indicator of Serotonin Syndrome, a potentially life-threatening condition that, while rare with buspirone alone, can occur, particularly if the client is taking other medications that increase serotonin (like SSRIs or MAOIs).

The nurse should report these signs immediately because:

Sweating (Diaphoresis) and High Fever (Hyperthermia) are core components of the triad of symptoms for Serotonin Syndrome (autonomic instability).
Serotonin Syndrome also involves changes in mental status (e.g., confusion, hallucinations, which is option D) and neuromuscular hyperactivity (e.g., muscle rigidity, tremors).
This is a medical emergency that requires immediate intervention to prevent complications like rhabdomyolysis, metabolic acidosis, and renal failure.

In comparison:

C. Decreased appetite is a common, generally mild, and manageable side effect.
D. Hallucinations are a serious central nervous system side effect, but when presented alongside the life-threatening systemic signs of Serotonin Syndrome (A), option A represents the more urgent and dangerous adverse reaction.
B. Discolored urine is not a standard adverse effect and would need investigation, but is not as acutely critical as signs of Serotonin Syndrome.

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Correct Answer is C

Explanation

Choice A: Lock the doors to the unit and secure windows so they cannot be opened: While removing potential means of self-harm from the environment is a safety precaution, it is not the most immediate or effective intervention for a client actively experiencing suicidal ideation who has refused a safety contract. Locking doors and windows may increase anxiety and feelings of entrapment, potentially exacerbating the client's distress and hindering open communication. Additionally, it may not address underlying emotional and psychological factors contributing to the suicidal thoughts.

Choice B: Remove any objects from the client's environment that could be used for self-harm: Similar to Choice A, removing potential means can be a helpful safety measure but should not be the primary intervention in this situation. It is important to recognize that clients can find alternative means if they are determined to self-harm, and focusing solely on environmental control can detract from addressing the root of the suicidal crisis.

Choice C: Assign a staff member to stay with the client at times: This option prioritizes the client's safety and emotional well-being by providing constant support and supervision. A dedicated staff member can:

Monitor the client's behavior and emotional state closely, potentially identifying early warning signs of impending self-harm.

Provide open and non-judgmental support, allowing the client to express their thoughts and feelings freely without fear of being alone with their distress.

Engage in therapeutic communication, helping the client explore alternative coping mechanisms and develop safety plans for managing suicidal urges.

Alert other healthcare professionals if the client's condition deteriorates or if there is any immediate risk of self- harm.

Offer a sense of security and reassurance, knowing someone is constantly available to listen and intervene if needed.

Choice D: Provide the client with plastic eating utensils for meals: While this precaution may reduce the risk of self- harm at mealtimes, it addresses a very specific concern and does not address the broader issue of the client's suicidal ideation. It is also important to consider that plastic utensils may not be effective in preventing self-harm if the client is determined and resourceful.

Therefore, assigning a staff member to stay with the client at all times is the most appropriate and immediate action to prioritize the client's safety and emotional well-being in this situation. This approach fosters open communication, provides continuous support, and allows for early intervention if necessary. While environmental controls and risk assessments can be valuable complementary strategies, they should not overshadow the importance of close human connection and emotional support in crisis situations.

A. Fear of rejection from staff. B. Narcissistic Personality Disorder. C. A side effect of antidepressant medication. D. Attempt to reduce anxiety.

Correct Answer is D

Explanation

Choice A rationale: Fear of rejection from staff is not typically a driving factor for the repetitive behaviors seen in OCD. While social anxiety can be a component of many mental health disorders, the compulsions in OCD are usually driven by intrusive thoughts or fears that are specific to the individual, rather than fears about social rejection.

Choice B rationale: Narcissistic Personality Disorder (NPD) is a separate condition from OCD. While individuals with NPD may exhibit certain repetitive behaviors, these are typically driven by a need for admiration and a lack of empathy for others, rather than the intrusive thoughts and fears that drive the compulsions in OCD12.

Choice C rationale: While certain medications can have side effects that might cause unusual behaviors, the repetitive behaviors (compulsions) seen in OCD are not typically a side effect of antidepressant medications. In fact, certain types of antidepressants are often used in the treatment of OCD12.

Choice D rationale: The repetitive behaviors observed in individuals with OCD, such as repeatedly applying, removing, and reapplying makeup, are indeed attempts to reduce anxiety. These individuals experience intrusive thoughts, fears, or images (obsessions) that cause significant anxiety. The repetitive behaviors (compulsions) are performed in an attempt to alleviate the distress caused by these obsessions. Despite the temporary relief, the individual often ends up trapped in a cycle of obsessions and compulsions.

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A nurse is caring for a client who has generalized anxiety disorder and is taking buspirone. Which of the following adverse effects should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority?

Correct Answer is C

Explanation

A nurse observes a client who has Obsessive-Compulsive Disorder (OCD) repeatedly applying, removing, and then reapplying makeup.The nurse identifies that repetitive behavior in a client with OCD is due to which of the following underlying reasons?

Correct Answer is D

Explanation

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