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?

Insomnia.

Constipation.

Dry mouth.

Excessive sweating.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Insomnia is a common side effect of sertraline and many other antidepressant medications. It is not indicative of serotonin syndrome, a potentially life-threatening condition characterized by excessive serotonin levels in the brain.

Choice B rationale:

Constipation is a side effect of some antidepressant medications, including sertraline. It is not a symptom of serotonin syndrome, which presents with a combination of symptoms such as confusion, agitation, rapid heart rate, dilated pupils, muscle rigidity, and high body temperature.

Choice C rationale:

Dry mouth is another common side effect of sertraline and many other medications. While uncomfortable, it is not a sign of serotonin syndrome. Symptoms of serotonin syndrome are neurological and autonomic, involving changes in mental status, muscle activity, and vital signs.

Choice D rationale:

Excessive sweating, also known as diaphoresis, can be a symptom of serotonin syndrome. Other symptoms might include agitation, tremor, hyperreflexia, fever, dilated pupils, and diarrhea. If a patient experiences these symptoms while taking sertraline, it could indicate serotonin syndrome and should be reported immediately for medical evaluation.

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Correct Answer is C

Explanation

Choice A rationale:

Beginning ball squeezing exercises is not advisable immediately after a modified radical mastectomy. The client's arm on the affected side needs time to heal, and strenuous exercises can strain the surgical site, increase pain, and potentially disrupt the healing process.

Choice B rationale:

Wearing a bra with wire support is not recommended, especially in the early postoperative period. Underwire bras can irritate the surgical site and interfere with the healing process. Patients are usually advised to wear soft, non-underwire bras or special post-surgical bras designed for comfort and support.

Choice C rationale:

Avoiding the use of the affected arm for eating is the correct instruction. Protecting the surgical site and preventing strain is essential for proper healing. Encouraging the client to use the opposite arm for activities like eating can minimize movement in the affected area, reducing the risk of complications.

Choice D rationale:

Using deodorant under the affected arm is not recommended immediately after surgery. The surgical site needs to be kept clean and dry to prevent infection and promote healing. Deodorants, especially those containing chemicals or fragrances, can irritate the skin and increase the risk of complications. Patients are usually advised to avoid applying any products to the surgical area until it is fully healed.

A. Delegate non-nursing tasks to ancillary staff. B. Stock client rooms with extra supplies. C. Assign dedicated equipment to each client's room. D. Change continuous IV infusion tubing every 24 hr.

Correct Answer is A

Explanation

- A is correct because delegating non-nursing tasks to ancillary staff allows nurses to focus on more complex and skilled tasks that require their expertise and judgment, thus improving efficiency and quality of care.

- B is incorrect because stocking client rooms with extra supplies increases waste and costs, as well as clutter and infection risk.

- C is incorrect because assigning dedicated equipment to each client's room reduces availability and accessibility of equipment for other clients, as well as increases maintenance and cleaning costs.

- D is incorrect because changing continuous IV infusion tubing every 24 hr is not cost-effective, as it does not reduce the risk of infection significantly compared to changing it every 72 hr, according to current evidence-based practice guidelines.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is A

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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?