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 D
Explanation
A. "How long has this been going on?":
While this question is important for gathering more information, it may come across as more investigative or less empathetic at this initial stage of the conversation.
B. "Why do you think you are so anxious?":
While it's important to understand the client's perspective, this response might come across as confrontational or judgmental. It's better to create an open and non-judgmental environment for the client to share their feelings.
C. "Have you talked to your parents about this yet?":
This response assumes that the client has parents to talk to and may not be relevant for all clients. It's also important to establish trust and rapport with the client before asking about their support network.
D. "It sounds like you're having a difficult time.":
This response is empathetic and validating. It acknowledges the client's feelings without making assumptions or demands, creating a supportive environment for further discussion.
Correct Answer is A
Explanation
A. The client responds to questions with disorganized speech:
Disorganized speech is a hallmark of acute mania, often reflecting racing thoughts, pressured speech, and difficulty staying on topic.
B. The client reports that voices are telling him to write a novel:
Reporting that voices are telling the client to write a novel suggests auditory hallucinations, which can occur in various psychiatric conditions, not specifically indicative of acute mania.
C. The client's spouse reports that the client has recently gained weight:
Weight gain is not a typical hallmark of acute mania. In fact, during manic episodes, individuals might experience decreased appetite and sleep, leading to potential weight loss.
D. The client is dressed in all black:
Dressing in all black is not a specific sign of acute mania. While changes in clothing choices or appearance can sometimes be associated with mood changes, this finding alone is not indicative of acute mania.
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