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 A
Explanation
A. Schedule regular weigh-in times: Monitoring the client's weight on a regular schedule is important in managing anorexia nervosa. It helps track progress and any potential complications related to weight loss.
B. Allow the client to eat at any time: For individuals with anorexia nervosa, there is typically a structured meal plan that is carefully monitored by healthcare professionals. Allowing the client to eat at any time might disrupt the planned nutritional intake.
C. Provide privacy when friends visit: Privacy is important, but it should be balanced with ensuring the client's safety and adherence to the treatment plan. Visitors might need to be supervised to prevent any behaviors that could exacerbate the disorder.
D. Compliment the client for weight gain: While support and encouragement are important, complimenting a client for weight gain might inadvertently reinforce a focus on body image and reinforce disordered eating behavior. It's crucial to provide positive reinforcement for adherence to the treatment plan and progress in recovery, rather than emphasizing weight changes.
Correct Answer is B
Explanation
A. Praise the client for looking at herself in a mirror.
While body image concerns are common in anorexia nervosa, praising the client for looking at herself in a mirror may inadvertently reinforce the focus on appearance and body image, which can be counterproductive.
B. Ask the client to agree to talk to a nurse whenever she feels the urge to exercise.
Explanation: For a client with anorexia nervosa, overexercising can be part of the unhealthy behaviors associated with the disorder. Collaborative communication is important in addressing and managing these behaviors. Asking the client to agree to talk to a nurse whenever the urge to exercise arises is a supportive approach. It allows the nurse to provide emotional support, explore the client's motivations and triggers for overexercising, and work together on finding healthier coping strategies.
C. Reprimand the client about the potential damage that has occurred due to overexercising her body.
Reprimanding the client may lead to feelings of guilt and shame, which are counterproductive in supporting recovery. A more empathetic and supportive approach is needed.
D. Restrict the client from being weighed.
Restricting the client from being weighed might exacerbate anxiety around weight gain and contribute to the client's preoccupation with weight. However, monitoring weight under the supervision of healthcare professionals is important in managing anorexia nervosa.
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