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 {"dropdown-group-1":"C"}

Explanation

Electrolyte imbalance in pregnant clients is often associated with conditions that lead to dehydration and nutritional deficiencies. In this scenario, the key indicators are persistent nausea and significant weight loss.

Persistent nausea can lead to reduced food and fluid intake. This condition, especially if prolonged, can cause dehydration and electrolyte imbalances due to the loss of essential minerals and nutrients that are not being replenished due to inadequate dietary intake.
Significant weight loss, particularly the amount described in the scenario (6.8 kg or 15 lb), is a clear sign of inadequate nutritional intake and can further exacerbate the risk of electrolyte imbalance. It indicates that the body is not receiving enough nutrients, which is crucial for maintaining electrolyte balance.

The other options, while related to diet and fluid intake, are more specific to the client's eating habits and do not directly point to the primary cause of potential electrolyte imbalance in the context of this scenario. Therefore, the most comprehensive and medically relevant choice is (A) Persistent nausea and significant weight loss.

A. Providing postmortem care for a client who has recently died. B. Performing a simple dressing change on a client's foot. C. Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile. D. Emptying an indwelling urinary catheter bag for a client while wearing clean gloves.

Correct Answer is C

Explanation

Choice A rationale:

Providing postmortem care for a client who has recently died does not require immediate intervention by the charge nurse, as it is a standard nursing responsibility to provide postmortem care with dignity and respect to the deceased client. The AP can proceed with this task independently.

Choice B rationale:

Performing a simple dressing change on a client's foot is within the scope of practice for an assistive personnel (AP) and does not require immediate intervention by the charge nurse, assuming the AP is competent and trained to perform this task.

Choice C rationale:

Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile is not sufficient. Alcohol is not effective against C. Difficile spores.

Choice D rationale:

Clean gloves are sufficient for this task, as they do provide adequate protection against the transmission of infections.

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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

A nurse is providing phone advice for a client who is pregnant. Exhibits here Complete the following sentence by using the copy pasting from the list of options. The client is at risk for experiencingelectrolyte imbalancedue to the

Correct Answer is {"dropdown-group-1":"C"}

Explanation

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Correct Answer is C

Explanation

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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?