NCLEX-RN
NCLEX RN Psychiatric Questions Questions
Extract:
The following scenario applies to the next 1 items
The emergency department (ED) nurse is caring for a 54-year-old female
Item 1 of 1
History and Physical
1655 - 54-year-old female presents with her husband with reports of her 'not acting right.' The husband reports that three days ago, he noticed his wife 'acting odd' and reported her experiencing intermittent abdominal cramping, sweating heavily, and irritability. Today, the client woke up completely disoriented, feeling hot, and reporting that her heart was beating out of her chest. The client's husband reports that one week ago, she had such low motivation to get out of bed that he believes she has been taking more paroxetine than prescribed. The husband called their doctor and was instructed to report to the ED. The client has a medical history of chronic back pain, hypothyroidism, vitamin D deficiency, and peptic ulcer disease. She has recently been prescribed tramadol for back pain, which the husband says is contributing to her depressed mood. The client has a complicated and complex psychiatric history and is currently being treated for major depressive disorder - severe, generalized anxiety disorder, and dependent personality disorder. The client's current medications include levothyroxine, paroxetine, vitamin D, tramadol, and esomeprazole. The client was recently involuntarily hospitalized for four days because she was observed attempting to kill herself with a large kitchen knife. Prior to this, the client was being treated with outpatient electroconvulsive therapy (ECT), which she later became non-adherent with, and thus, the treatment was abandoned. Since the discontinuation of the ECT, the client was prescribed paroxetine. On exam, the client is hyper-alert, disoriented to place and situation, appears somewhat agitated, and has myoclonus of the legs and feet. She has generalized diaphoresis. Her gait is disturbed, and she requires maximum assistance to the bathroom, where she has been having bouts of diarrhea. The speech was somewhat pressured and nonsensical at times. She denied hallucinations and suicidal ideations. Vital signs: T 104° F (40° C), P 134, RR 21, BP 168/99, pulse oximetry reading 95% on room air.
Question 1 of 5
The nurse is reviewing the client's history & physical and inserted a peripheral venous access device (VAD). Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
Action to Take
Potential Condition
Parameter to Monitor
Correct Answer: B (serotonin syndrome), A (request a prescription for diazepam), C (implement seizure precautions), C (electrocardiogram), C (temperature)
Rationale: The client's symptoms (hyperthermia, myoclonus, diaphoresis, disorientation) suggest serotonin syndrome, likely due to paroxetine overdose. Diazepam can manage agitation and seizures, and seizure precautions are necessary. Monitoring ECG and temperature assesses cardiac stability and hyperthermia resolution.
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