Medical History: The patient is on Naltrexone 50mg PO once daily and Fluoxetine 20mg PO every morning.

The nurse has reviewed the client’s electronic health record.

Which of the following client findings require immediate follow-up by the nurse? (Select all that apply.)

Sexual behaviors

Frequency of hospitalizations

Sodium level

Hepatitis Viral Study (HAA) results

Answer and Explanation

Correct Answer : C,D

Choice C rationale:

Sodium level is a critical electrolyte that plays a vital role in maintaining fluid balance, nerve and muscle function, and blood pressure. Naltrexone, one of the medications the patient is taking, has the potential to cause hyponatremia (low sodium levels) as a side effect. Hyponatremia can manifest with various symptoms, including headache, nausea, vomiting, confusion, seizures, and even coma in severe cases. Prompt recognition and management of hyponatremia are crucial to prevent serious complications.

Rationale for Immediate

Potential for Hyponatremia: Naltrexone, an opioid antagonist, can interfere with the body's ability to regulate sodium levels, leading to hyponatremia.

Serious Consequences of Hyponatremia: Low sodium levels can disrupt vital bodily functions, potentially causing neurological symptoms, seizures, and even coma.

Need for Prompt Intervention: Early detection and correction of hyponatremia are essential to prevent adverse outcomes.

Monitoring and Management: The nurse should assess the patient's sodium level, monitor for signs and symptoms of hyponatremia, and initiate appropriate interventions as needed, such as fluid restriction or electrolyte replacement.

Choice D rationale:

Hepatitis Viral Study (HAA) results are essential for determining the patient's hepatitis A status. Hepatitis A is a highly contagious liver infection that can cause significant illness. Fluoxetine, the other medication the patient is taking, can potentially cause liver damage in rare cases. Therefore, it's crucial to ensure that the patient does not have hepatitis A before initiating or continuing Fluoxetine therapy.

Rationale for Immediate

Potential Liver Injury: Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), has a rare but potential risk of hepatotoxicity (liver damage).

Hepatitis A Risk: Hepatitis A infection can further exacerbate liver injury, increasing the risk of complications.

Baseline Assessment: HAA results provide information about the patient's hepatitis A status, aiding in risk assessment and management decisions.

Monitoring and Precautions: If the patient tests positive for hepatitis A, the nurse should initiate appropriate precautions to prevent transmission and closely monitor liver function during Fluoxetine therapy.

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Correct Answer is D

Explanation

A rationale:

Spending time with friends can be a protective factor against suicide, as it provides social support and connection.

While isolation can be a risk factor, spending time with friends does not inherently indicate suicide risk.

It's important to assess the quality of relationships and the presence of other risk factors.

Choice B rationale:

Regular sleep patterns often indicate healthy mental health.

Significant changes in sleep patterns (either too much or too little) can be warning signs, but consistent sleep of 9 hours is not typically a concern.

It's essential to evaluate sleep quality and any recent changes.

Choice C rationale:

Religious involvement can provide a sense of purpose, belonging, and support, which can be protective against suicide.

While it's not a guarantee of protection, it's generally a positive factor.

It's crucial to assess the individual's level of engagement and any potential conflicts within their religious beliefs.

Choice D rationale:

Exposure to suicide, especially in a close connection like a coach, can significantly increase a person's risk for suicide.

It can lead to normalization of suicide as a coping mechanism, imitation of behavior, or triggering of underlying mental health issues.

This is a strong risk factor that warrants immediate attention and assessment.

A. Ideas of reference. B. Grandeur. C. Somatic delusion. D. Erotomania.

Correct Answer is A

Explanation

Choice A rationale:

Ideas of reference are a type of delusion in which a person believes that unrelated events, objects, or actions in the environment have personal significance or meaning specifically directed towards them. In this case, the client with schizophrenia misinterpreted the group's laughter as mockery directed specifically at them, even though the story was unrelated to them.

Here's a detailed explanation of why the other choices are incorrect: B. Grandeur:

Grandiosity involves an inflated sense of self-importance, power, or identity. It's not evident in this scenario, as the client isn't expressing beliefs of exceptional abilities or status. C. Somatic delusion:

Somatic delusions focus on bodily functions or sensations, such as believing organs are rotting or insects are crawling under the skin. The client's outburst isn't related to bodily concerns. D. Erotomania:

Erotomania is a delusion where a person believes someone of higher status is in love with them. It's not applicable in this situation as the client's belief isn't about romantic interest.

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Medical History: The patient is on Naltrexone 50mg PO once daily and Fluoxetine 20mg PO every morning. The nurse has reviewed the client’s electronic health record. Which of the following client findings require immediate follow-up by the nurse? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse in a community clinic is speaking to a parent who expresses concern for her adolescent son. Which of the following statements by the mother should indicate to the nurse that the adolescent is at risk for suicide?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

A nurse is conversing with a client diagnosed with schizophrenia. Suddenly, the client expresses fear, stating, “I’m scared. Can you hear that? The voices are instructing me to do awful things.” Which of the following responses from the nurse would be suitable?

A nurse is caring for a client who has borderline personality disorder (BPD). What should the nurse monitor in the client’s Medication Administration Record?

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A nurse is discussing the possible physical effects of alcohol withdrawal with a newly licensed nurse. Which of the following effects should the nurse include? (Select all that apply.)

A nurse is reinforcing dietary teaching with a client who has a new prescription for a monoamine oxidase Inhibitor (MAOI). Which of the following foods should the nurse instruct the client to avoid while taking an MAOI?

A nurse is caring for a client who has an anxiety disorder. Which of the following findings should the nurse recognize as a manifestation of mild anxiety?

Medical History: The patient is on Naltrexone 50mg PO once daily and Fluoxetine 20mg PO every morning.

The nurse has reviewed the client’s electronic health record.

Which of the following client findings require immediate follow-up by the nurse? (Select all that apply.)