A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of the following is the priority nursing intervention?
Padding side rails to prevent injury.
Applying a cooling blanket.
Administering an anticonvulsant.
Preparing for artificial ventilation.
The Correct Answer is D
While preventing injury is important, it is not the highest priority when the client's respiratory and neurological functions are compromised. Managing the client's breathing takes precedence.
B. Applying a cooling blanket.
While hyperthermia (high fever) is a symptom of serotonin syndrome, the immediate concern is ensuring the client's breathing and neurological stability. Cooling measures can be beneficial, but they come after addressing the more critical issues.
C. Administering an anticonvulsant.
While anticonvulsants might be used to control seizures, preparing for artificial ventilation takes priority, as the client's airway and oxygenation must be secured before addressing other symptoms.
D. Preparing for artificial ventilation.
Explanation: Serotonin syndrome is a potentially life-threatening condition caused by an excess of serotonin in the body, often resulting from interactions between medications that affect serotonin levels. Severe manifestations of serotonin syndrome can include high fever, muscle rigidity, agitation, seizures, and even coma. In cases of severe serotonin syndrome, the client's neurological and respiratory functions can be compromised, making it crucial to ensure adequate ventilation and oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Helping the client identify positive personality traits.
While addressing self-esteem and positive personality traits is valuable for the client's overall well-being, it is not the immediate priority during the detoxification phase. Ensuring physiological safety comes first.
B. Providing for adequate hydration and rest.
Explanation: The detoxification process from alcohol can result in withdrawal symptoms that range from mild discomfort to severe medical complications. Adequate hydration and rest are essential during this phase to manage withdrawal symptoms and prevent potential complications such as dehydration, electrolyte imbalances, and seizures. Maintaining the client's physiological stability is of utmost importance.
C. Educating the client about the consequences of alcohol misuse.
Providing education about the consequences of alcohol misuse is important for the client's understanding and motivation for recovery, but it's not the primary concern during the initial detoxification phase.
D. Confronting the use of denial and other defense mechanisms.
Addressing denial and defense mechanisms is important for therapy, but it might not be the immediate priority. Physiological stabilization through hydration and rest takes precedence in the detoxification phase.
Correct Answer is ["2"]
Explanation
To calculate the number of capsules that the nurse should administer per dose, the nurse should first divide the total daily dose of tetracycline by the number of doses per day. This gives the dose per administration:
2 grams / 4 doses = 0.5 grams per dose
Next, the nurse should convert the dose from grams to milligrams, since the available capsules are in milligrams. There are 1000 milligrams in one gram, so the nurse should multiply the dose by 1000:
0.5 grams x 1000 mg/g = 500 mg per dose
Finally, the nurse should divide the dose in milligrams by the strength of each capsule, which is 250 mg. This gives the number of capsules that the nurse should administer per dose:
500 mg / 250 mg/capsule = 2 capsules per dose
Therefore, the nurse should administer 2 capsules of tetracycline every 6 hours to the client.
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