A nurse is teaching a client who has a new prescription for sertralihe to treat depression. For which of the following findings should the nurse instruct the client to monitor and report immediately as indicating serotonin syndrome?
Insomnia
Constipation
Dry mouth
Excessive sweating
The Correct Answer is D
A. Insomnia: While insomnia can be a side effect of sertraline, it is not typically associated with serotonin syndrome. However, if the insomnia is severe or accompanied by other symptoms of serotonin syndrome, it should be reported to the healthcare provider.
B. Constipation: Constipation is a common side effect of sertraline but is not indicative of serotonin syndrome. It is important to monitor for constipation and manage it appropriately but not as an indicator of serotonin syndrome.
C. Dry mouth: Dry mouth is another common side effect of sertraline but is not specific to serotonin syndrome. While uncomfortable, it does not typically require immediate reporting unless severe or accompanied by other concerning symptoms.
D. Excessive sweating: Excessive sweating, also known as diaphoresis, is a hallmark symptom of serotonin syndrome. It is a significant indicator of serotonin toxicity and should be reported immediately to the healthcare provider for further evaluation and management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Veracity: Veracity refers to the ethical principle of truthfulness or honesty. By informing the client about the potential adverse effects of transcranial magnetic stimulation (TMS) and reassuring them that it should not affect their memory, the nurse is demonstrating truthfulness and providing accurate information to the client.
B. Fidelity: Fidelity pertains to the ethical principle of faithfulness or honoring commitments and promises made to clients. While important, fidelity is not directly demonstrated in this scenario.
C. Beneficence: Beneficence involves the ethical principle of doing good or acting in the best interest of the client to promote their well-being. While providing information about the potential adverse effects of TMS is aligned with beneficence, the specific action described in the scenario focuses more on truthfulness (veracity).
D. Autonomy: Autonomy refers to the ethical principle of respecting the client's right to make their own decisions and choices regarding their healthcare. While autonomy is important in healthcare decision-making, it is not directly demonstrated in this scenario, as the nurse is providing information rather than facilitating the client's decision-making process.
Correct Answer is B
Explanation
A. Diaphoresis: Diaphoresis, or excessive sweating, is a common side effect of clozapine and may not necessarily indicate a need for immediate intervention. However, it should be documented and monitored for any changes.
B. Fever: Fever can be a sign of infection, which is a serious concern in clients taking clozapine due to the risk of agranulocytosis, a potentially life-threatening side effect characterized by a severe decrease in white blood cell count. Any signs of infection, including fever, should be reported promptly to the provider for further evaluation and management.
C. Polyuria: Polyuria, or excessive urination, is not typically associated with clozapine use and may be indicative of other underlying issues such as diabetes mellitus or diabetes insipidus. While it should be assessed and managed appropriately, it is not specifically related to clozapine administration and may not require immediate reporting to the provider.
D. Diarrhea: Diarrhea is a common gastrointestinal side effect of clozapine and may occur due to its effects on the gastrointestinal system. While persistent or severe diarrhea should be monitored and managed, it is not typically considered a serious adverse reaction that requires immediate reporting to the provider unless it is accompanied by other concerning symptoms.
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