A nurse is teaching a client who has a new prescription for sertraline to treat depression. For which of the following findings should the nurse instruct the client to monitor and report immediately as indicating serotonin syndrome?
Dry mouth
Constipation
Insomnia
Excessive sweating
The Correct Answer is D
A. Dry mouth is a common side effect but not a sign of serotonin syndrome.
B. Constipation is another possible side effect but is not an emergency.
C. Insomnia can occur but does not indicate serotonin syndrome.
D. This is the correct answer. Excessive sweating (along with agitation, confusion, fever, and muscle rigidity) is a sign of serotonin syndrome, a potentially life-threatening condition.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Calcium – Spironolactone does not significantly impact calcium levels, so avoiding calcium supplements is unnecessary.
B. Potassium – This is the correct answer. Spironolactone is a potassium-sparing diuretic, which can lead to hyperkalemia. Clients should avoid potassium supplements and potassium-rich foods to prevent dangerous elevations in serum potassium levels.
C. Iron – Spironolactone does not have a direct effect on iron metabolism, so iron supplementation is not contraindicated.
D. Magnesium – Although spironolactone does not have a strong impact on magnesium levels, excessive magnesium intake is not a primary concern with this medication.
Correct Answer is C
Explanation
A. Data comparison should be done after establishing the standards and collecting data.
B. While data collection is important, the first step is to determine what the accepted hand hygiene standards are.
C. This is the correct answer. The first step in an audit process is to determine the accepted hand hygiene standards to provide a basis for evaluation.
D. Corrective measures should only be taken after data has been collected and analyzed.
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