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 C
Explanation
A. Human papillomavirus (HPV): HPV vaccination is typically recommended for adolescents and young adults to prevent HPV infection, which can lead to cervical cancer and other related diseases. It is not typically indicated for older adults.
B. Rotavirus: Rotavirus vaccination is recommended for infants to protect against severe diarrhea caused by rotavirus infection. It is not indicated for older adults.
C. Herpes zoster: Herpes zoster vaccination, also known as the shingles vaccine, is recommended for older adults to prevent shingles, a painful rash caused by the reactivation of the varicella-zoster virus. The risk of developing shingles increases with age, and vaccination can reduce the risk and severity of the condition.
D. Diphtheria, tetanus, and acellular pertussis (DTaP): DTaP vaccination is typically administered to children to protect against diphtheria, tetanus, and pertussis (whooping cough). Tdap is the vaccine formulation recommended for adults, which includes tetanus, diphtheria, and pertussis components.
Correct Answer is A
Explanation
A. Adding water to the formula will decrease its osmolarity, reducing the risk of hyperosmolar dehydration. This action helps to dilute the formula and make it more isotonic, which is better tolerated by the client's gastrointestinal tract.
B. Repositioning the NG tube may be necessary if there are issues with tube placement or if the tube has migrated. However, it is not directly related to addressing hyperosmolar dehydration.
C. Increasing the rate of formula delivery may exacerbate hyperosmolar dehydration by introducing more concentrated formula into the gastrointestinal tract, leading to further dehydration.
D. Switching to a lactose-free formula may be appropriate if the client has lactose intolerance, but it does not address the issue of hyperosmolar dehydration. Adding water to the formula is the more appropriate intervention in this scenario to decrease osmolarity and prevent dehydration.
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