A nurse in an acute care facility is caring for a toddler.

Exhibits

For each assessment finding below, click to specify if the assessment finding is consistent with Crohn's disease, appendicitis, or intussusception. Each finding may support more than 1 disease process.

Rationale for Correct Choices:

• Serotonin syndrome: The client’s symptoms recent SSRI dose increase indicate possible serotonin toxicity. Serotonin syndrome occurs when excessive serotonin accumulates in the body, typically following dose escalation or interaction between serotonergic medications. It is a medical emergency that can progress to seizures or death if not promptly identified and treated.

• Adverse effects of paroxetine: The increase in paroxetine dosage one week prior likely triggered excessive serotonergic activity. Paroxetine, an SSRI, elevates serotonin levels, and dose escalation can precipitate serotonin syndrome.

Rationale for Incorrect Choices:

• Generalized anxiety disorder: Although the client has a history of anxiety, the acute onset of fever, disorientation, and autonomic instability points to a physiological reaction rather than worsening anxiety. Anxiety may cause restlessness but does not produce hyperthermia or confusion.

• Neuroleptic malignant syndrome: This condition is associated with antipsychotic drugs, not SSRIs like paroxetine. While both syndromes can present with fever and altered mental status, the client’s medication profile and timing support serotonin toxicity instead.

• Feelings of hopelessness: Although ongoing hopelessness is part of the client’s depression, it does not explain the acute physical manifestations. Emotional symptoms may persist with depression, but fever and disorientation indicate a pharmacologic rather than psychological cause.

• Anxiety: Anxiety alone cannot account for the client’s fever, disorientation, or abdominal pain. These findings suggest a systemic reaction consistent with serotonin excess, not a purely psychological state.

Rationale:
A. Suction the ET to remove secretions: Secretions in the airway can increase resistance, leading to higher peak inspiratory pressures. Suctioning helps clear the obstruction, restoring normal airflow and reducing pressure within the ventilator circuit.

B. Assess the ET for a cuff leak: A cuff leak would result in decreased pressure and trigger a low-pressure alarm rather than an increased peak airway pressure. In this case, the issue relates to increased resistance or obstruction, not a loss of airway seal.

C. Verify the placement of the ET: Incorrect placement of the ET tube can cause ventilation issues, but it usually leads to decreased or absent breath sounds and oxygen desaturation rather than an increase in peak pressure.

D. Check for a disconnection in the ventilator tubing: A disconnection in the circuit causes a sudden drop in pressure, triggering a low-pressure alarm instead of a high-pressure one. Therefore, this action is not related to resolving increased peak airway pressure.

E. Check for a kink in the ventilator tubing: A kink or obstruction in the ventilator tubing increases airway resistance, causing higher peak pressures. Straightening or clearing the tubing restores normal airflow and helps resolve the high-pressure alarm effectively.