An older client has recently been prescribed sertraline (Zoloft). The client's spouse is taking paroxetine (Paxil). A nurse assesses that the client is experiencing restlessness, tachycardia, diaphoresis, and tremors
Which complication should a nurse suspect, and why? 1. Neuroleptic malignant syndrome; caused by ingestion of two different seratonin reuptake inhibitors (SSRIs)
2. Neuroleptic malignant syndrome; caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI)
3. Serotonin syndrome; possibly caused by ingestion of an SSRI and an MAOI
4. Serotonin syndrome; possibly caused by ingestion of two different SSRIs
4
Rationale: The nurse should suspect that the client is suffering from serotonin syndrome; possibly caused by ingesting two different SSRI's (sertraline and paroxetine). Symptoms of serotonin syndrome include confusion, agitation, tachycardia, hypertension, nausea, abdominal pain, myoclonus, muscle rigidity, fever, sweating, and tremor.
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During an examination of a 3-year-old child, the nurse notices a bruit over the left temporal area. The nurse should:
a. Continue the examination because a bruit is a normal finding for this age. b. Check for the bruit again in 1 hour. c. Notify the parents that a bruit has been detected in their child. d. Stop the examination, and notify the physician.
The nurse talks with a clinic patient by phone and discovers the patient is not taking her medication as instructed. The patient was given only verbal instructions in her teaching session. The nurse should now have the patient do which of the following?
a. Listen to the nurse as the nurse repeats the instructions by phone. b. Call every day, and the nurse will repeat the instructions until learned. c. Return to the clinic to receive other teaching methods. d. Have a family member take the instructions by phone.
During the active phase of labor, many women:
a. are sociable and excited, but cooperative. b. begin to experience the urge to push. c. lose control and are irritable. d. request pain medication.
A client with mental retardation has been accused of first-degree murder. There has been a plea of diminished capacity. Which of the following describes diminished capacity?
A) Used by individuals who are informed of their legal rights B) Entered in the presence of a mental disease at the time of the commission of an alleged criminal act C) The criminal act occurred because of the client's illness but the client is not responsible for his or her behavior D) Because of a mental impairment, the defendant could not form the mental state required for a particular offense