Patient Data

Exhibits

The nurse reviews the prescriptions and assessment data.

Click to indicate which interventions could help reduce symptoms if added to the plan of care. Each row must have one response option selected.

Administer 2 mg of diazepam intravenously.

Induce paralysis.

Apply cooling blankets.

Apply 1 L/min oxygen.

Ensure that the antidepressant medication is discontinued

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Diazepam is a benzodiazepine that can be effective in managing symptoms of serotonin syndrome, including agitation and myoclonus. It can help reduce muscle rigidity and provide sedation.

Inducing paralysis is not appropriate in this scenario. The patient’s symptoms suggest serotonin syndrome or another type of stimulant intoxication, and paralysis could worsen the situation or mask underlying symptoms.

The patient has a high fever (102°F or 38.8°C) and significant diaphoresis. Cooling blankets can help manage hyperthermia and reduce body temperature.

The patient’s oxygen saturation is 97% on room air, indicating adequate oxygenation. There is no immediate need for supplemental oxygen at this time.

If the patient is suspected to have serotonin syndrome, which can be triggered by the use of certain antidepressants (particularly SSRIs), discontinuing the offending medication is crucial.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Inserting a urinary catheter is a skill that typically requires a licensed nurse's expertise.

B. Titrating oxygen requires assessment and adjustment based on clinical findings, which is outside the UAP’s scope of practice.

C. Procuring platelet products from the blood bank is a non-clinical task that can be safely assigned to a UAP.

D. Monitoring an IV infusion rate involves clinical judgment and is typically performed by a licensed nurse.

A. Shuffling gait and stooped posture. B. Rocks back and forth in the chair. C. Muscle spasms of the back and neck. D. Lip smacking and frequent eye blinking.

Correct Answer is C

Explanation

A. Shuffling gait and stooped posture are common side effects of antipsychotic medications and may require intervention but are not immediately dangerous.

B. Rocking back and forth in the chair can be a self-soothing behavior in individuals with schizophrenia and usually does not require immediate intervention.

C. Muscle spasms of the back and neck (dystonia) can be a sign of a serious side effect of antipsychotic medications known as extrapyramidal symptoms and require immediate intervention to prevent complications such as airway obstruction.

D. Lip smacking and frequent eye blinking can indicate tardive dyskinesia, a long-term side effect of antipsychotic medication, but it is not an immediate emergency.

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Patient Data Exhibits The nurse reviews the prescriptions and assessment data. Click to indicate which interventions could help reduce symptoms if added to the plan of care. Each row must have one response option selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?

Correct Answer is C

Explanation

The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention?

Correct Answer is C

Explanation

A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider?

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair. Which intervention is most important for the nurse to include in the plan of care?

The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?

A client is admitted to the mental health unit for feelings of depression secondary to a positive HIV report. To provide a safe milieu for this client, which action should the nurse take?

The nurse is providing education to a client who receives a prescription for zolpidem. Which information about the medication should the nurse include?

The nurse is providing dietary education to a client in end stage kidney failure who requires dialysis three times a week. Which information is important for the nurse to include about the client's daily diet?

Patient Data

Exhibits

The nurse reviews the prescriptions and assessment data.

Click to indicate which interventions could help reduce symptoms if added to the plan of care. Each row must have one response option selected.