The practical nurse (PN) is caring for a client receiving a prescription for paroxetine who suddenly exhibits restlessness, tachycardia, fever, and elevated blood pressure. Which action should the PN implement first?

Withhold the next dose and contact the healthcare provider

Obtain a cooling blanket from the hospital central supply department

Take the client to a quiet area and provide reassurance

Administer a PRN prescription for benzodiazepine and acetaminophen

Answer and Explanation

The Correct Answer is A

Choice A reason: Restlessness, tachycardia, fever, and hypertension suggest serotonin syndrome, a life-threatening paroxetine side effect due to excessive serotonin. Withholding the dose and contacting the provider prevents further serotonin accumulation, allowing urgent assessment and intervention to stabilize the client’s neurological and cardiovascular status.

Choice B reason: A cooling blanket addresses fever but is not the first action for serotonin syndrome. Withholding paroxetine and consulting the provider are critical to stop the syndrome’s progression, as fever is a symptom, not the cause, making this choice secondary to halting the drug.

Choice C reason: Taking the client to a quiet area may reduce stimulation but does not address serotonin syndrome’s physiological cause. Paroxetine’s serotonin excess drives symptoms, requiring drug cessation and medical intervention, not just reassurance, as this condition can rapidly worsen, making this choice inadequate.

Choice D reason: Administering benzodiazepine and acetaminophen is premature without provider guidance, as serotonin syndrome requires specific treatments, like cyproheptadine. Paroxetine must be stopped first, and the provider consulted to confirm diagnosis and manage symptoms, making this choice unsafe and reactive.

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Correct Answer is A

Explanation

Choice A reason: Rivaroxaban, a direct oral anticoagulant, inhibits factor Xa, increasing bleeding risk. Bruising on arms and legs may indicate excessive anticoagulation, potentially leading to severe hemorrhage. Immediate reporting is critical to assess bleeding risk, adjust dosing, or initiate interventions to prevent life-threatening complications.

Choice B reason: Genital itching and burning with discharge suggest a possible infection or allergic reaction, not a direct adverse effect of rivaroxaban. These symptoms are unrelated to its anticoagulant mechanism, which primarily affects hemostasis, making this choice incorrect for immediate reporting.

Choice C reason: Diminished taste and smell are not recognized side effects of rivaroxaban. These symptoms may relate to other conditions, like neurological or infectious issues, but do not reflect the drug’s anticoagulant effects. This choice is irrelevant to rivaroxaban’s adverse effect profile.

Choice D reason: Hard, dry stools indicate constipation, a non-urgent side effect not typically associated with rivaroxaban. While gastrointestinal issues may occur, bleeding risks are more critical. This symptom does not warrant immediate reporting compared to bruising, which signals potential hemorrhage.

A. Ask the client’s spouse why the client is sitting outside of their home B. Notify the home health supervisor that the client’s condition is improved C. Remind the client to wear sunblock and protective clothing while in sunlight D. Encourage the client to stay indoors until the course of treatment is completed

Correct Answer is C

Explanation

Choice A reason: Asking the spouse why the client is outside is irrelevant to the clinical concern. Fluoroquinolones cause photosensitivity, increasing sunburn risk. The focus should be on protecting the client from UV exposure, not investigating their location, making this choice unhelpful for addressing the drug’s side effect.

Choice B reason: Notifying the supervisor about an improved condition is premature and unrelated to the client being outdoors. Sitting outside does not indicate recovery, and the priority is addressing photosensitivity from fluoroquinolones, which risks skin damage, making this choice incorrect.

Choice C reason: Fluoroquinolones, like ciprofloxacin, increase photosensitivity by sensitizing skin to UV light, causing severe sunburn or rash. Reminding the client to use sunblock and protective clothing prevents dermal damage during sunlight exposure, directly addressing the drug’s side effect and ensuring safety.

Choice D reason: Encouraging staying indoors is overly restrictive and impractical. Photosensitivity can be managed with sunblock and clothing, allowing safe outdoor activity. This choice unnecessarily limits the client’s mobility, as proper precautions effectively mitigate the risk of UV-related skin damage.

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The practical nurse (PN) is caring for a client receiving a prescription for paroxetine who suddenly exhibits restlessness, tachycardia, fever, and elevated blood pressure. Which action should the PN implement first?

Nursing Test Bank

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