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 A

Explanation

A. Stay with the client for 15 min following meals: Staying with the client for 15 minutes after meals is a common practice to ensure that they do not engage in behaviors like purging or hiding food. It provides supervision and support to prevent the client from engaging in harmful activities.

B. Weigh the client every day for the first week of acute care: Weighing the client daily is not typically recommended, as it may increase anxiety and focus on weight. Weighing may be done periodically, but the frequency should be tailored to the client’s needs and the treatment.

C. Schedule the client for a daily exercise program: Exercise may be restricted or minimized in clients with anorexia nervosa, especially in the acute phase of treatment, as excessive exercise can worsen the condition and interfere with recovery.

D. Discuss food-related topics with the client during meals: Discussing food-related topics during meals may increase anxiety or pressure related to food. The focus during meals should be on providing a supportive, non-judgmental environment that encourages normal eating patterns.

A. Occupational therapy B. Palliative care C. Respite care D. Hospice care

Correct Answer is C

Explanation

A. Occupational therapy: Occupational therapy focuses on helping clients improve their ability to perform daily activities. While beneficial for individuals with Alzheimer's, it does not specifically address the partner’s need for temporary relief from caregiving duties.
B. Palliative care: Palliative care focuses on providing relief from symptoms and improving the quality of life for clients with serious illnesses. While appropriate for end-of-life care, it may not address the partner’s immediate need for respite from caregiving.
C. Respite care: Respite care provides temporary relief for caregivers by allowing them to take a break while ensuring their loved one continues to receive appropriate care. This is the most appropriate referral for the partner, who is seeking time for themselves.
D. Hospice care: Hospice care is focused on end-of-life care, offering comfort and support for clients with terminal illnesses. It is not the best option in this case, as the client is not necessarily at the end of life but has Alzheimer's disease, which is a progressive condition.

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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 is caring for a client who is newly admitted for the treatment of anorexia nervosa. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is performing a home visit on a client who has Alzheimer's disease and their partner. The partner states, "I wish I had some time to myself and run errands, but I need to be here all the time." Which of the following referrals should the nurse recommend to the client's partner?

Correct Answer is C

Explanation

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