A nurse is reviewing the medical records for a group of clients prior to administering the clients' medications. For which of the following clients should the nurse withhold the prescribed medication and notify the provider?

A client who is taking venlafaxine and exhibits frequent yawning and weight loss

A client who is taking olanzapine and reports frequent urination

A client who is taking fluoxetine and exhibits muscle rigidity and tachycardia

A client who is taking nortriptyline and reports nausea and dry mouth

Answer and Explanation

The Correct Answer is C

A. Venlafaxine and frequent yawning/weight loss: Frequent yawning and weight loss are not typical signs of an adverse reaction to venlafaxine. These symptoms can occur with various conditions, but they do not necessarily require withholding the medication.
B. Olanzapine and frequent urination: Frequent urination is not a known side effect of olanzapine. However, the nurse should assess the client for other factors contributing to this symptom. It may not be severe enough to require withholding the medication without further evaluation.
C. Fluoxetine and muscle rigidity/tachycardia: Muscle rigidity and tachycardia could indicate serotonin syndrome, a potentially life-threatening condition. This requires immediate intervention, and the medication should be withheld while notifying the provider for further evaluation and treatment.
D. Nortriptyline and nausea/dry mouth: Nausea and dry mouth are common side effects of tricyclic antidepressants like nortriptyline. These symptoms typically do not require withholding the medication, but the nurse should monitor the client for any worsening or additional adverse effects.

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Correct Answer is C

Explanation

A. High self-esteem: High self-esteem is not a risk factor for alcohol use disorder. In fact, individuals with alcohol use disorder often struggle with low self-esteem and emotional distress.

B. Low socioeconomic status: While low socioeconomic status can be a risk factor for various mental health and substance use issues, it is not as directly linked to alcohol use disorder as other factors, such as genetics or environmental influences.

C. Genetic predisposition: Genetic predisposition is a significant risk factor for alcohol use disorder. Family history and genetic factors can influence the likelihood of developing alcohol use disorder, making it a key factor to include in the presentation.

D. History of maternal infection during pregnancy: While maternal infections during pregnancy can have various effects on fetal development, they are not directly linked to the development of alcohol use disorder.

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

Explanation

Rationale for correct choices:

Remaining neutral: The nurse should remain neutral to avoid reinforcing or escalating the client’s grandiose beliefs. This helps maintain trust and creates space for self-reflection without judgment.
Explaining that the client is not entitled to play on a professional team: Gently addressing the client’s unrealistic expectations helps them understand the reality of their situation and fosters a more grounded perspective on their goals.

Rationale for incorrect choices:

Questioning the client's abilities: Directly questioning the client's abilities could be seen as confrontational and may increase defensiveness. A more constructive approach would focus on challenging unrealistic beliefs.
Challenging the client's feelings of grandiosity: Challenging grandiosity directly can make the client feel attacked. It’s better to educate and explain the reality of their expectations in a supportive way.
Supporting the client's fear of abandonment: The client does not appear to express abandonment fears in this case. The issue is more related to grandiosity, so focusing on this would be more effective.
Suggesting another sport: Suggesting a different sport might divert attention from the core issue—grandiosity. Addressing the client's distorted self-image is more important before offering alternatives.

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Body system	Findings
Neurological	Impaired cognition Insomnia Seizures
Cardiovascular	Increased blood pressure Increased heart rate Diaphoresis
Gastrointestinal	Lack of appetite Vomiting
Musculoskeletal	Tremulousness Malaise

A nurse is reviewing the medical records for a group of clients prior to administering the clients' medications. For which of the following clients should the nurse withhold the prescribed medication and notify the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse at a community health center is preparing a presentation on alcohol use disorder. Which of the following risk factors should the nurse include in the presentation?

Correct Answer is C

Explanation

A nurse in the student health clinic is caring for a client Exhibits Complete the following sentence by using the lists of options. The nurse should care for the client by dropdownanddropdown.

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

Explanation

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