The spouse of a man being treated with sertraline (Zoloft) calls to report that he had a grand mal seizure. Prior to the seizure, he had seemed confused and his forehead felt hot. The man does not have a seizure-disorder history. Which action should the nurse direct the spouse to take?

Correct Answer: B

Rationale: Step 1: The man had a grand mal seizure, confusion, and a hot forehead, which are signs of serotonin syndrome, a serious side effect of sertraline. Step 2: The nurse should direct the spouse to hold all medications to prevent further serotonin syndrome symptoms. Step 3: Calling 911 for immediate transportation to the hospital is crucial for prompt evaluation and treatment of the seizure and serotonin syndrome. Step 4: This action ensures the man receives appropriate medical care to address the seizure and manage the potential serotonin syndrome. Summary: - Choice A is incorrect as monitoring the patient at home is not sufficient for a serious medical emergency like serotonin syndrome. - Choice C is incorrect as simply holding tonight's sertraline and encouraging fluids does not address the immediate need for medical intervention. - Choice D is incorrect as administering an antipyretic drug does not address the underlying cause of the seizure and confusion, which is serotonin syndrome.

Correct Answer: A

Rationale: The correct answer is A: Risk for deficient fluid volume. The priority nursing diagnosis in this case is to address the client's physical needs to ensure their safety and well-being. The client's mutism and immobility put them at risk for dehydration and malnutrition. By prioritizing the risk for deficient fluid volume, the nurse can address the immediate physiological needs of the client. Choice B: Impaired physical mobility is incorrect because while the client is motionless, the immediate concern is addressing the risk of dehydration. Choice C: Impaired social interaction is incorrect as addressing social interaction is not the priority when the client's physical needs are not being met. Choice D: Ineffective coping is incorrect because the client's presentation is indicative of a more urgent physical need for hydration and nutrition.

Correct Answer: B

Rationale: The correct answer is B: Assessing the client for physical problems. This is the initial priority because the client's muteness and motionless state could be due to an underlying physical issue that needs immediate attention, such as dehydration, malnutrition, or infection. By assessing for physical problems first, the nurse can rule out any urgent medical concerns before addressing the client's mental health needs. A: Orienting the client to the unit - While important, this can be done after addressing any physical problems. C: Establishing a nonthreatening relationship - Also essential, but assessing physical health takes precedence. D: Reinforcing reality with the client - Not the immediate priority; physical assessment should come first.

Correct Answer: A

Rationale: Step 1: Paranoid schizophrenia is a subtype that tends to have a better prognosis compared to other types. Step 2: The statement that the disorder responds well to treatment and may not recur aligns with the typical course of paranoid schizophrenia. Step 3: With proper medication and therapy, individuals with paranoid schizophrenia can experience significant improvement and have periods of stability. Step 4: Recurrence of symptoms is less likely compared to other types of schizophrenia. Step 5: Therefore, choice A is correct as it provides accurate information about the prognosis of paranoid schizophrenia. Summary: Choice B is incorrect because not all types of schizophrenia are chronic relapsing disorders. Choice C is incorrect as outcomes are not solely determined by prehospital disorganization. Choice D is incorrect as partial remission is not the usual outcome for paranoid schizophrenia.

Correct Answer: D

Rationale: The correct answer is D because wearing elastic support hose, drinking adequate fluids, and changing positions slowly can help prevent postural hypotension associated with antipsychotic medications. Elastic support hose can improve blood circulation and prevent blood pooling in the legs. Adequate fluid intake can help maintain blood volume and blood pressure. Changing positions slowly can prevent sudden drops in blood pressure upon standing. Choice A (anticholinergic drug) is incorrect as it may worsen symptoms of schizophrenia. Choice B (sugarless gum or candy) is unrelated to postural hypotension. Choice C (increasing sleep and rest breaks) may help with fatigue but does not address postural hypotension directly.