The nurse is caring for a patient in the emergency department who reports the onset of agitation, confusion, muscle twitching, diaphoresis, and fever about 12 hours after beginning a new prescription for escitalopram [Lexapro]. Which is the most likely explanation for these symptoms?
A. Cholinergic crisis
B. Serotonin syndrome
C. Depressive psychosis
D. Escitalopram overdose
Answer: B. Serotonin syndrome
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What is the reason for things the nurse does, whether at work or off duty?
1. Personal motivation 2. Facility policies 3. Fear of reprisals 4. Parental expectations
An older adult client with a history of congestive heart failure (CHF) has a low-grade fever. Which action by the nurse is appropriate?
A) Provide warm blankets. B) Restrict fluids. C) Encourage getting out of bed to ambulate. D) Notify the healthcare provider.
A female client with chronic hepatitis B has been prescribed recombinant interferon alpha-2b in combination with ribavirin. Which of the following instructions should a nurse provide this client?
A) Avoid calcium-rich foods. C) Use strict birth control methods. B) Maintain an exercise regimen. D) Avoid hot water baths or soaks.
A client is admitted to a healthcare facility with third-degree burns. Which of the following is the extent of tissue damage seen in third-degree burns?
A) Epidermis with minimal dermis involvement B) Entire epidermis and a portion of dermis C) Entire epidermis, dermis, and subcutaneous fat D) Minimal damage of the epidermis