Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assisting with the care for a newly admitted client who has major depressive disorder.
Select 1 condition and 1 client finding to fill in each blank in the following sentence (Separate using a comma).
The client is at risk for developing
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Full Explanation
The client is at risk for developing Serotonin syndrome due to the Client's intake of St. John's wort
Explanation:
St. John's wort is an herbal supplement that can interact with certain medications, including selective serotonin reuptake inhibitors (SSRIs) and other medications that increase serotonin levels. Serotonin syndrome is a potentially life-threatening condition characterized by an excess of serotonin in the body.
In the given scenario, the nurse should identify:
Condition: The client's intake of St. John's wort
Client Finding: At risk for developing serotonin syndrome
This is because the use of St. John's wort, combined with medications that affect serotonin levels, increases the risk of serotonin syndrome. The nurse should monitor for symptoms of serotonin syndrome, such as changes in vital signs, hyperthermia, altered mental status, and neuromuscular abnormalities. If serotonin syndrome is suspected, medical attention should be sought promptly.
Similar Questions
A nurse is caring for a client who has schizophrenia.
Select the "3" findings that should indicate to the nurse the client is experiencing negative symptoms related to their schizophrenia.
A. Blood pressure
Blood pressure: Blood pressure is not mentioned in the nurse's notes, and it is not directly indicative of negative symptoms in schizophrenia.
B. Lack of motivation
Lack of motivation: The client refusing to eat or drink, not engaging in conversation, and not wanting to go to therapy sessions are indicative of a lack of motivation, which is a negative symptom.
C. Change in behaviour
Change in behavior: While there is a change in behavior mentioned in the notes (refusing to eat or drink, not engaging in conversation), the specific behavioral changes described are more closely associated with negative symptoms. Negative symptoms involve a reduction or loss of normal functions.
D. Lack of energy
Lack of energy: The client's slow movements and desire to sleep suggest a lack of energy, another negative symptom associated with schizophrenia.
E. Withdrawn
Withdrawn: The client's withdrawal from social interaction, as evidenced by not engaging in conversation and wanting to sleep, is characteristic of withdrawal, which is a negative symptom.
Full Explanation
The "3" findings that should indicate to the nurse that the client is experiencing negative symptoms related to their schizophrenia are:
B.Lack of motivation
D.Lack of energy
E.Withdrawn
Explanation:
Negative symptoms in schizophrenia involve deficits or reductions in normal emotional and behavioral functioning. In the provided nurse's notes:
Blood pressure: Blood pressure is not mentioned in the nurse's notes, and it is not directly indicative of negative symptoms in schizophrenia.
B. Lack of motivation: The client refusing to eat or drink, not engaging in conversation, and not wanting to go to therapy sessions are indicative of a lack of motivation, which is a negative symptom.
C. Change in behavior: While there is a change in behavior mentioned in the notes (refusing to eat or drink, not engaging in conversation), the specific behavioral changes described are more closely associated with negative symptoms. Negative symptoms involve a reduction or loss of normal functions.
D. Lack of energy: The client's slow movements and desire to sleep suggest a lack of energy, another negative symptom associated with schizophrenia.
E. Withdrawn: The client's withdrawal from social interaction, as evidenced by not engaging in conversation and wanting to sleep, is characteristic of withdrawal, which is a negative symptom.
A nurse is caring for a client who has paranoid schizophrenia and a new prescription for risperidone. The client asks the nurse what the s is supposed to do. Which of the following responses should the nurse make?
A. "This medication will prevent depress
Stating that the medication will prevent depression is not accurate. Risperidone primarily addresses symptoms of psychosis and does not specifically target depression.
B. "This medication will improve your mood."
Indicating that the medication will improve mood is not the primary purpose of risperidone. Its focus is on managing psychotic symptoms rather than directly impacting mood.
C. "This medication will decrease your anxiety."
Mentioning that the medication will decrease anxiety is not the primary action of risperidone. While it might indirectly reduce anxiety associated with psychotic symptoms, it's not its primary function.
D. "This medication will clear your thinking"
"This medication will clear your thinking."Risperidone is an antipsychotic medication commonly used to manage symptoms of schizophrenia, including hallucinations, delusions, and disorganized thinking. While it won't directly improve mood, decrease anxiety, or prevent depression, it aims to alleviate symptoms related to psychosis, allowing for clearer and more organized thinking by reducing hallucinations and delusions.
Full Explanation
A. Stating that the medication will prevent depression is not accurate. Risperidone primarily addresses symptoms of psychosis and does not specifically target depression.
B. Indicating that the medication will improve mood is not the primary purpose of risperidone. Its focus is on managing psychotic symptoms rather than directly impacting mood.
C. Mentioning that the medication will decrease anxiety is not the primary action of risperidone. While it might indirectly reduce anxiety associated with psychotic symptoms, it's not its primary function.
D. "This medication will clear your thinking."
Risperidone is an antipsychotic medication commonly used to manage symptoms of schizophrenia, including hallucinations, delusions, and disorganized thinking. While it won't directly improve mood, decrease anxiety, or prevent depression, it aims to alleviate symptoms related to psychosis, allowing for clearer and more organized thinking by reducing hallucinations and delusions.
A nurse is collecting data from a newly-admitted client who has bipolar disorder and is displaying manic behavior. Which of the following findings should the nurse expect? (Select all that apply.)
A. Exhibiting clang associations
Exhibiting clang associations: Correct. Clang associations involve the repetition of words or phrases based on sound rather than meaning and are often seen in manic states.
B. interacting with others in a flirtatious way
Interacting with others in a flirtatious way: Correct. Manic individuals may exhibit increased social and sexual behaviors, including being flirtatious.
C. Reports sleeping for long periods of time
Reports sleeping for long periods of time: Incorrect. Manic episodes are typically associated with decreased need for sleep rather than increased. Reports of sleeping for long periods would be more indicative of a depressive episode in bipolar disorder.
D. Talking in rapid continuous speech
Talking in rapid continuous speech: Correct. Rapid and continuous speech is a common characteristic of manic episodes in bipolar disorder.
E. Reports spending large sums of money
Reports spending large sums of money: Correct. Excessive spending is a common manifestation of manic behavior, often without consideration of the consequences.
Full Explanation
A. Exhibiting clang associations: Correct. Clang associations involve the repetition of words or phrases based on sound rather than meaning and are often seen in manic states.
B. Interacting with others in a flirtatious way: Correct. Manic individuals may exhibit increased social and sexual behaviors, including being flirtatious.
C. Reports sleeping for long periods of time: Incorrect. Manic episodes are typically associated with decreased need for sleep rather than increased. Reports of sleeping for long periods would be more indicative of a depressive episode in bipolar disorder.
D. Talking in rapid continuous speech: Correct. Rapid and continuous speech is a common characteristic of manic episodes in bipolar disorder.
E. Reports spending large sums of money: Correct. Excessive spending is a common manifestation of manic behavior, often without consideration of the consequences.