Author Question: The situations in which the nurse has a duty to intervene and report are when (more than one answer ... (Read 83 times)

segrsyd · **on:** Jul 19, 2018

The situations in which the nurse has a duty to intervene and report are when (more than one answer
may be correct)

A. a peer is unable to write behavioral outcomes.
B. a physician consults the Physician's Desk Reference relative to dosing.
C. a peer arrives for duty in an alcohol-impaired state.
D. a team member has been discovered to have violated the boundaries of a vulnerable client.

Question 2

A client being treated with paroxetine (Paxil) 50 mg po daily for depression reports to the clinic
nurse that he took a few extra tablets earlier in the day and feels bad now.

The nurse should assess
(more than one answer may be correct)
A. vital signs.
B. for increased suicidal ideation.
C. for presence of abdominal pain and diarrhea.
D. for hyperactivity or feelings of restlessness.

momtoalll · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

ANS:
C, D
Rationale: Both instances jeopardize client safety. Option A is of concern but can be resolved
informally. Option B is acceptable practice.

Answer to Question 2

A, C, D
Rationale: The client is taking the maximum dose of this SSRI and has ingested an additional
unknown amount of the drug. Central serotonin syndrome must be considered. Symptoms include
abdominal pain, diarrhea, tachycardia, elevated blood pressure, hyperpyrexia, increased motor
activity, and muscle spasms. Central serotonin syndrome may progress to a full medical emergency
if not treated early. Option B: Although assessing for suicidal ideation is never inappropriate, in this
situation physiological symptoms should be the initial focus.