A patient is brought to the emergency department by her brother, who reports that the patient became very agitated and 'started hallucinating.' Further assessment reveals tachycardia, incoordination, vomiting, and diarrhea. The brother states that the patient is taking paroxetine for depression. Which of the following would the nurse most likely suspect?

Correct Answer: C

Rationale: The correct answer is C: Serotonin syndrome. The patient's symptoms of agitation, hallucinations, tachycardia, incoordination, vomiting, and diarrhea are consistent with serotonin syndrome, a potentially life-threatening condition caused by excessive serotonin levels. Paroxetine is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression, which can lead to serotonin syndrome when combined with other serotonergic medications. Neuroleptic malignant syndrome (choice A) presents with muscle rigidity, fever, and altered mental status. Acute dystonic reaction (choice B) is characterized by sudden muscle contractions. Hypothyroidism (choice D) does not typically present with symptoms like agitation, hallucinations, and tachycardia.

Correct Answer: B

Rationale: The correct answer is B: Boundary setting. When working with a client diagnosed with antisocial personality disorder, it is crucial for the nurse to focus on teaching the family about setting boundaries. This is important because individuals with this disorder often have difficulty respecting others' boundaries and may engage in manipulative or harmful behaviors. By establishing clear boundaries, the family can protect themselves and the client from potential harm or exploitation. Explanation of why the other choices are incorrect: A: Anger management - While anger management may be important in some cases, it is not the primary focus when dealing with antisocial personality disorder. The core issue lies in the individual's lack of empathy, disregard for rules, and manipulative behavior. C: Medication therapy - Medication may be used to manage certain symptoms associated with antisocial personality disorder, but it is not the primary intervention. The focus should be on behavioral and therapeutic approaches. D: Self-responsibility - While self-responsibility is important, individuals with antis

Correct Answer: C

Rationale: The correct answer is C because it reflects active listening and empathy. The nurse acknowledges the patient's feelings and opens the door for further discussion. Choice A dismisses the patient's feelings and may come off as insensitive. Choice B provides positive reinforcement but overlooks the patient's emotional state. Choice D generalizes the patient's feelings without addressing their specific concerns. Overall, choice C encourages the patient to express their thoughts and promotes therapeutic communication.

Correct Answer: D

Rationale: The correct answer is D because it focuses on the patient's past behavior in response to stress, providing insight into her coping strategies. By understanding how she has dealt with stress before, the nurse can anticipate her current response. Choice A is too focused on the cause of job loss, not the patient's emotional response. Choice B is too narrow, not addressing broader coping mechanisms. Choice C is future-oriented, not addressing the patient's current emotional state.

Correct Answer: D

Rationale: The correct answer is D because confronting the staff member and reporting concerns to a supervisor immediately is crucial for addressing the issue promptly and ensuring patient safety. This approach allows for professional intervention and support. Choice A is incorrect as it may compromise patient care. Choice B may enable the behavior and is not a professional response. Choice C could be appropriate, but immediate action is needed to address the potential risk to patients and the staff member.