The nurse notes that a client who has been receiving paroxetine (Paxil) for symptoms of major depression and whose sensorium had been clear begins to behave as though somewhat confused and elated
The nurse also notes the presence of restlessness, muscle jerking, and diaphoresis. The nurse should assess these symptoms as probable:
1. Neuroleptic malignant syndrome
2. Anticholinergic blockade
3. Serotonin syndrome
4. Dystonia
ANS: 3
These are symptoms of serotonin syndrome, a condition that requires medical intervention. The other options are not associated with SSRI therapy.
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The nurse prepares to discharge an older man who has heart failure and is in stable condition, when his wife states that she will avoid sexual activities with him because of his heart disease
Which of the following factors should the nurse use in patient teaching about sexual activity for an older adult with heart failure? a. An older adult with heart failure should avoid sexual relations because of the de-mand it places on the heart. b. Sexual relations and climbing six flights of stairs expend the same amount of energy. c. Fear and lack of knowledge can cause older people to reduce their sexual activity unnecessarily. d. Sexuality is a private matter between the older man and his wife.
A client with a diagnosis of acute appendicitis is awaiting surgical intervention. The nurse listens to bowel sounds and hears none and observes that the abdomen is rigid and boardlike
What complication does the nurse determine may be occurring at this time? A) Constipation B) Paralytic ileus C) Peritonitis D) Accumulation of gas
If a patient has not voided in the 8 hours following the removal of an indwelling catheter or has voided less than 240 mL, a nurse should
1. Notify the health-care provider. 2. Insert a new catheter and obtain a urine specimen. 3. Perform a bladder scan. 4. Irrigate the urethra.
The nurse delegates the hygienic care of a male patient to the unregulated care provider
In reviewing the patient assignment, the nurse instructs the unregulated care provider to make sure to use an electric razor to shave the patient with which of the following conditions? a. Thrombocytopenia b. Congestive heart failure c. Osteoarthritis d. Pneumonia