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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Gabapentin and phenytoin are not directly associated with causing vitamin B deficiencies. However, certain antiseizure medications could potentially affect nutrient absorption over time.

B) A client who has chronic alcohol use disorder.

Explanation:

Chronic alcohol use disorder can lead to a deficiency in several B vitamins, particularly vitamin B1 (thiamine), vitamin B2 (riboflavin), vitamin B3 (niacin), vitamin B6 (pyridoxine), vitamin B9 (folate), and vitamin B12 (cobalamin). Alcohol interferes with the absorption and utilization of these vitamins in the body, and individuals with alcohol use disorder are often at risk for malnutrition and vitamin deficiencies.

C) A client who takes heparin to prevent deep vein thrombosis:

Heparin is an anticoagulant and does not directly impact the absorption or utilization of vitamin B.

D) A client who has asthma:

Asthma itself does not significantly increase the risk of vitamin B deficiencies. Vitamin B deficiencies are more commonly associated with factors like malnutrition, certain medical conditions, or medications that impact absorption, as seen in chronic alcohol use disorder.

A. You are being unreasonable, and I will not call your doctor at this hour." B. Go back to your room, and I'll try to get in touch with your doctor." C. You must be very upset about something D. I can't call a doctor in the middle of the night unless it's an emergency."

Correct Answer is C

Explanation

A. "You are being unreasonable, and I will not call your doctor at this hour."

This response is confrontational and dismissive of the client's request. It does not promote a therapeutic interaction and might escalate the situation.

B. "Go back to your room, and I'll try to get in touch with your doctor."

This response might temporarily calm the client, but it’s misleading if the nurse does not intend to call the doctor. It also avoids addressing the client's immediate emotional needs and could result in a loss of trust if the nurse doesn’t follow through.

C. "You must be very upset about something."

This is the most therapeutic response. It acknowledges the client’s feelings without judgment and opens up communication. It allows the nurse to explore the client’s concerns, which is essential in providing appropriate care and support in a psychiatric setting.

D. "I can't call a doctor in the middle of the night unless it's an emergency."

While this statement is factually correct, it can come across as dismissive and could escalate the client's agitation. It does not acknowledge the client's emotions and might make the client feel that their concerns are not being taken seriously.

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A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of the following is the priority nursing intervention?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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