The nurse cares for four patients receiving SSRIs. Which assessment finding warrants the nurse's priority attention?
a. Dry mouth and stuffy nose
b. Malaise and frontal headache
c. Confusion, agitation, and hyperthermia
d. Constipation, photophobia, and anhidrosis
C
The correct response suggests serotonin syndrome, an acute medical problem requiring immediate medical and nursing attention. The distracters are examples of anticholinergic effects and are not considered emergencies.
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Which instructions should a nurse provide to a patient just before a scheduled spirometry test? (Select all that apply.)
a. Avoid smoking 4 to 6 hours before test. b. Do not use bronchodilator medications for at least 4 hours. c. Exercise for a few minutes. d. Drink 2 glasses of fluid. e. Avoid eating.
The best way for a parent to encourage their toddler to eat a variety of foods is to
a. offer rewards for trying new foods. b. make new foods look like favorite foods. c. allow free access to foods at all times. d. eat a variety of foods themselves.
Which manifestation in a 5-month-old child could indicate visual problems?
a. Lack of binocularity b. Visual acuity of 20/50 c. Strabismus d. Hyperopia
The nurse has just begun administering intravenous streptokinase (Streptase). The nurse assesses vital signs and notes a temperature of 37° C, a heart rate of 70 beats per minute, and a blood pressure of 88/58 mm Hg
The nurse will contact the provider to a. request an adjustment of the streptokinase dose. b. request an order for aminocaproic acid (Amicar). c. request epinephrine to prevent anaphylaxis. d. report potential hemorrhage in this patient.