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A nurse is teaching a client who has a new prescription for sertraline to treat depression. For which of the following findings should the nurse instruct the client to monitor and report immediately as indicating serotonin syndrome?

Dry mouth

Constipation

Insomnia

Excessive sweating

Answer and Explanation

The Correct Answer is D

A. Dry mouth is a common side effect but not a sign of serotonin syndrome.

B. Constipation is another possible side effect but is not an emergency.

C. Insomnia can occur but does not indicate serotonin syndrome.

D. This is the correct answer. Excessive sweating (along with agitation, confusion, fever, and muscle rigidity) is a sign of serotonin syndrome, a potentially life-threatening condition.

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Correct Answer is B

Explanation

A. Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears – This describes the Rinne test, not the Weber test.

B. Place a vibrating tuning fork on the top of the child's head – Correct. The Weber test assesses hearing loss by placing a tuning fork on the midline of the skull to determine if sound is heard equally in both ears.

C. Whisper a statement to the child from 0.6 m (2 feet) away – This describes the whisper test, not the Weber test.

D. Apply a pair of headphones securely over the child's ears – Not part of the Weber test; this is used for audiometry testing.

A. Use clean technique for invasive procedures. B. Allow healthy children to visit. C. Monitor the client's temperature every 4 hr. D. Make sure the client's room is cleaned every 2 days.

Correct Answer is C

Explanation

A. Use clean technique for invasive procedures. – Incorrect. Sterile technique, not clean technique, is required to prevent infection in neutropenic clients.

B. Allow healthy children to visit. – Incorrect. Clients with neutropenia should avoid exposure to children due to the risk of infections.

C. Monitor the client's temperature every 4 hr. – Correct. Fever can indicate infection, which is life-threatening for neutropenic clients. Early detection is crucial.

D. Make sure the client's room is cleaned every 2 days. – Incorrect. The room should be cleaned daily to reduce infection risk.

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A nurse is teaching a client who has a new prescription for sertraline to treat depression. For which of the following findings should the nurse instruct the client to monitor and report immediately as indicating serotonin syndrome?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A school nurse is using Weber's test to check a child's hearing acuity. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is teaching a newly licensed nurse about caring for a client who has neutropenia. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds. Which of the following actions should the nurse take?

A nurse is teaching a client how to care for his behind-the-ear hearing aids. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is assessing a 24-month-old toddler at a well-child checkup. Which of the following findings indicates to the nurse that the toddler has a developmental delay?

A nurse is caring for a 3-year-old toddler who has dehydration. Which of the following findings should the nurse report to the provider?

A nurse performs a capillary blood glucose check for a client who has type 1 diabetes mellitus and obtains a reading of 64 mg/dL on the glucometer. Which of the following assessment findings should the nurse expect?

A nurse is reviewing the laboratory results of a client who has hypothyroidism. The client's calcium level is 7.6 mg/dL. When assessing the client, which of the following findings should the nurse expect?