A nurse is caring for a client who has major depressive disorder and was recently started on a SSRI. Which of the following assessment findings Indicates a toxic effect related to the SSRI?

Bradycardia

Xerostomia

Hypothermia

Hypertension

Answer and Explanation

The Correct Answer is D

Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed for major depressive disorder to increase serotonin levels in the central nervous system. While generally well tolerated, excessive serotonergic activity or drug accumulation can lead to toxicity, including autonomic instability and potentially life-threatening serotonin syndrome. Early recognition of toxic effects is essential, especially during initiation or dose adjustment periods. Nursing assessment focuses on identifying cardiovascular, neuromuscular, and mental status changes that may indicate excessive serotonergic activity.

Rationale:
A. Bradycardia is not typically associated with SSRI toxicity. Instead, serotonergic excess usually leads to autonomic hyperactivity, which more commonly manifests as tachycardia, hypertension, and diaphoresis. Bradycardia would suggest alternative etiologies such as conduction abnormalities or other medication effects.

B. Xerostomia (dry mouth) is a common and expected side effect of SSRIs due to anticholinergic-like effects, but it does not indicate toxicity. It is usually mild and manageable with supportive measures such as hydration and oral hygiene. It is not a marker of overdose or severe adverse reaction.

C. Hypothermia is not characteristic of SSRI toxicity. In serotonin syndrome or overdose, patients are more likely to present with hyperthermia due to increased metabolic activity and neuromuscular excitation. A low body temperature would be inconsistent with toxic serotonergic effects.

D. Hypertension is a key manifestation of SSRI toxicity, particularly in the context of serotonin syndrome, due to excessive sympathetic nervous system stimulation. In the setting of a Serotonin syndrome, autonomic instability can lead to elevated blood pressure, tachycardia, and hyperthermia. This finding indicates possible toxic accumulation and requires immediate intervention.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Safe delegation of nursing tasks involving intravenous therapy requires distinguishing between actions that require clinical judgment and those that are observational in nature. A client receiving 0.45% sodium chloride via continuous infusion requires careful monitoring for complications such as infiltration, occlusion, or pump malfunction. Assistive personnel (AP) may assist with basic observations and reporting but cannot perform tasks that require assessment, clinical decision-making, or manipulation of sterile equipment. The nurse remains responsible for managing and adjusting IV therapy.

Rationale:
A. Reporting IV infusion alarms is an appropriate task for assistive personnel because it involves observation and communication rather than clinical decision-making. In a client receiving 0.45% sodium chloride, pump alarms may indicate occlusion, infiltration, or empty fluid containers. The AP should promptly notify the nurse so that appropriate assessment and intervention can be performed.

B. Regulating the IV flow rate is not appropriate for assistive personnel because it requires clinical judgment and adjustment based on the client’s condition and prescribed rate. Changes in IV infusion require nursing assessment to ensure safe fluid administration and prevent complications such as fluid overload or under-infusion.

C. Changing the IV solution bag is a sterile procedure that requires nursing knowledge and skill to maintain aseptic technique and ensure correct solution administration. Errors in IV fluid replacement can lead to serious complications such as electrolyte imbalance or infection. This task cannot be delegated to AP.

D. Calculating IV intake requires interpretation of fluid balance and clinical judgment to evaluate hydration status. This is part of nursing assessment and is essential in monitoring renal function, fluid overload, or deficit. Therefore, it is not appropriate for delegation to assistive personnel.

A. Administer betamethasone. B. Maintain bed rest. C. Obtain a 24-hr urine specimen. D. Monitor intake and output every hour. E. Assist RN with performing a vaginal examination every 12 hr. F. Provide a low-stimulation environment. G. Give antihypertensive medication.

Correct Answer is ["A","B","C","D","F","G"]

Explanation

Initiating the plan of care for a 31-week pregnant client with severe hypertension, proteinuria, thrombocytopenia, and elevated liver enzymes indicates a severe hypertensive disorder of pregnancy consistent with Preeclampsia with severe features. This condition places both maternal and fetal life at risk due to vasospasm, endothelial injury, and impaired placental perfusion. Priority care focuses on preventing progression to eclampsia, managing severe hypertension, monitoring organ function, and preparing for potential preterm delivery. Interventions aim to stabilize maternal status while optimizing fetal outcomes.

Rationale:
A. Administering betamethasone is appropriate because it accelerates fetal lung maturity in anticipation of possible preterm delivery. In severe preeclampsia, early delivery may be necessary to protect maternal and fetal health. Corticosteroids reduce neonatal respiratory distress syndrome by promoting surfactant production in the fetal lungs.

B. Maintaining bed rest helps reduce blood pressure and improves uteroplacental perfusion by decreasing physical and metabolic stress. Although strict bed rest is no longer universally recommended for all pregnancies, in severe preeclampsia it may help minimize stimulation and reduce risk of seizure activity. It also supports monitoring and stabilization in a controlled environment.

C. Obtaining a 24-hour urine specimen is important to quantify protein excretion and evaluate severity of renal involvement. Significant proteinuria is a hallmark of preeclampsia and helps guide diagnosis and ongoing management. It also provides baseline data for monitoring disease progression and response to treatment.

D. Monitoring intake and output hourly is essential due to risk of renal impairment and fluid shifts associated with preeclampsia. Reduced urine output may indicate worsening kidney perfusion or progression to end-organ dysfunction. Strict fluid monitoring also helps prevent fluid overload, which can lead to pulmonary edema.

E. Performing routine vaginal examinations every 12 hours is not indicated and may increase risk of infection or iatrogenic complications. In preeclampsia, unnecessary cervical manipulation should be avoided unless there is a clear obstetric indication for labor assessment. This intervention does not contribute to stabilization of maternal condition.

F. Providing a low-stimulation environment is critical to reduce the risk of seizure activity in severe preeclampsia. Minimizing noise, light, and stress helps decrease cerebral irritability and blood pressure fluctuations. This intervention is a key non-pharmacologic strategy to prevent progression to eclampsia.

G. Administering antihypertensive medication is necessary to control severe blood pressure elevations and reduce risk of stroke or placental abruption. Severe hypertension (≥160/110 mmHg) requires prompt pharmacologic management. Controlling blood pressure helps stabilize maternal condition and improve uteroplacental circulation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who has major depressive disorder and was recently started on a SSRI. Which of the following assessment findings Indicates a toxic effect related to the SSRI?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving 0.45% sodium chloride at 45 mL/hr by continuous IV Infusion. Which of the following tasks can the nurse delegate to the assistive personnel (AP)?

Correct Answer is A

Explanation

The nurse is continuing to assist with the care of the client. The nurse is assisting with Initiating the client's plan of care. Which of the following interventions should the nurse include? Select all that apply.

Correct Answer is ["A","B","C","D","F","G"]

Explanation

A nurse is assisting with client care on a medical unit when an individual who appears angry and agitated enters the unit and reveals a weapon. Which of the following actions should the nurse take?

A nurse is providing postmortem care to a client who just died. Which of the following actions should the nurse take?

A nurse at an outpatient clinic receives a call from a client who reports experiencing syncope after starting a new prescription for enalapril. Which of the following instructions should the nurse give the client?

A nurse is caring for a client who has dependent personality disorder. Which of the following manifestations should the nurse expect?

A nurse is caring for a client who has major depressive disorder and recently started taking antidepressants. Which of the following client statements should the nurse identify as the priority?

A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?

A nurse is contributing to the plan of care for a client who has dementia. Which of the following interventions should the nurse recommend?

A nurse is caring for an adolescent client who has type 1 diabetes mellitus. The adolescent reports mild symptoms and a serum glucose level of 55 g/dL. Which of the following should the nurse give the client?