The nurse is reviewing home medications for a client with a history of Major Depressive Disorder who has been taking sertraline for one year. The client states, “I did research and started taking St. John’s Wort to help with my depression in conjunction with sertraline.” Which of the following should the nurse observe for in the client?

Diaphoresis, tachycardia, and tremors

Fever, dystonia, and muscle rigidity

Symptoms of worsening depression and suicidal ideation

Spasms of the face, legs, and neck and bizarre facial movements

Answer and Explanation

The Correct Answer is A

Choice A reason: St. John’s Wort with sertraline increases serotonin levels, risking serotonin syndrome. Symptoms like diaphoresis, tachycardia, and tremors are classic signs, requiring urgent monitoring, making this the correct observation for the client.

Choice B reason: Fever, dystonia, and muscle rigidity suggest neuroleptic malignant syndrome, linked to antipsychotics, not sertraline or St. John’s Wort. This is unrelated to the drug interaction, making it incorrect.

Choice C reason: Worsening depression or suicidal ideation may occur with antidepressants, but St. John’s Wort more likely causes serotonin syndrome. These symptoms are less immediate, making this incorrect for the primary concern.

Choice D reason: Spasms and bizarre movements suggest tardive dyskinesia, associated with antipsychotics, not sertraline or St. John’s Wort. Serotonin syndrome is the primary risk, making this incorrect.

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Correct Answer is A

Explanation

Choice A reason: Acknowledging being skinny yet continuing restrictive behaviors indicates distorted body image, a core feature of anorexia nervosa. This reflects the client’s persistent fear of weight gain, making it the correct statement.

Choice B reason: High energy is atypical in anorexia, where fatigue is common due to malnutrition. This statement suggests a different condition, making it incorrect for anorexia nervosa identification.

Choice C reason: Searching for recipes may occur in anorexia but is not specific. It could reflect food preoccupation, but body image distortion is more definitive, making this incorrect.

Choice D reason: Enjoying form-fitting clothes to show off the body contradicts anorexia’s body dissatisfaction. Anorexia involves hiding thinness, making this incorrect compared to acknowledging skinniness.

A. Akinesia, dystonia, and pseudoparkinsonism. B. Hyperglycemia and diabetes. C. Dry mouth, constipation, and urinary retention. D. Muscle rigidity, hyperpyrexia, and tachycardia.

Correct Answer is C

Explanation

Choice A reason: Akinesia, dystonia, and pseudoparkinsonism are extrapyramidal symptoms caused by dopamine receptor blockade in the nigrostriatal pathway from typical antipsychotics. These motor-related side effects differ from anticholinergic effects, which involve muscarinic receptor blockade affecting the parasympathetic system. The client’s symptoms do not align with these movement disorders.

Choice B reason: Hyperglycemia and diabetes are metabolic side effects associated with atypical antipsychotics, not typical ones, due to effects on insulin regulation. Anticholinergic side effects from typical antipsychotics involve muscarinic receptor blockade, not metabolic pathways, making this an incorrect choice for the expected symptoms in this scenario.

Choice C reason: Typical antipsychotics, like haloperidol, block muscarinic receptors, causing anticholinergic side effects such as dry mouth (reduced salivation), constipation (decreased gastrointestinal motility), and urinary retention (impaired bladder contraction). These symptoms result from parasympathetic inhibition, precisely matching the expected side effect profile for long-term use of these medications.

Choice D reason: Muscle rigidity, hyperpyrexia, and tachycardia are symptoms of neuroleptic malignant syndrome, a rare, life-threatening reaction to antipsychotics, not routine anticholinergic side effects. This syndrome involves dopamine dysregulation and autonomic instability, distinct from the muscarinic receptor blockade causing anticholinergic effects, making it an incorrect choice.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client. Which of the following client statements should the nurse identify as an indication of anorexia nervosa?

Correct Answer is A

Explanation

The nurse is providing care to a client diagnosed with schizophrenia and is experiencing anticholinergic side effects from long-term use of typical antipsychotics. Which of the following symptoms would the nurse expect to see during an assessment?

Correct Answer is C

Explanation

A nurse on a mental health unit is caring for clients who have various depressive disorders. The nurse should identify which of the following client diagnoses as presenting the greatest risk for suicide?

A nurse is caring for a group of clients at a mental health facility. The nurse should identify that which of the following clients is exhibiting a warning sign of suicide?

A nurse is caring for a client who has opioid toxicity and has a respiratory rate of 6/min. Which of the following medications should the nurse plan to administer?

A nurse is providing care for a client who has recently returned from active combat and experienced the loss of a close friend during combat. Which of the following client statements indicates that the client is experiencing traumatic grief?

A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?

Which of the following clinical manifestations would a client with Huntington’s disease exhibit?

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client’s right nostril. Which of the following actions should the nurse take first?

A nurse is caring for a client who states, “I did not take my medication because my partner forgot to remind me.” The nurse should identify that the client is demonstrating which of the following defense mechanisms?