A nurse is teaching the parents of a child who has ADHD about methylphenidate. Which of the following statements should the nurse include in the teaching?

Choice A Reason: Insert a nasogastric tube

This choice is incorrect. Inserting a nasogastric tube is not the highest priority intervention for a client who has just received naloxone. While it may be necessary in some cases for other reasons, the immediate concern after naloxone administration is to ensure the client’s airway is open and they are breathing adequately. Naloxone reverses opioid effects, which can cause respiratory depression, so monitoring the airway and vital signs is crucial.

Choice B Reason: Monitor airway and vital signs

This choice is correct. The highest priority after administering naloxone is to monitor the client’s airway and vital signs. Naloxone can rapidly reverse opioid-induced respiratory depression, but its effects may wear off before the opioids are completely metabolized, leading to a risk of re-sedation and respiratory depression. Continuous monitoring ensures that any changes in the client’s condition are detected and managed promptly.

Choice C Reason: Insert an indwelling urinary catheter or monitor output

This choice is incorrect. While monitoring urine output can be important in assessing overall kidney function and fluid balance, it is not the highest priority immediately after naloxone administration. The primary concern is the client’s respiratory status and ensuring they maintain an open airway and adequate ventilation.

Choice D Reason: Anticipate and treat hyperpyrexia with cooling measures

This choice is incorrect. Hyperpyrexia (extremely high fever) is not a common immediate concern following naloxone administration. The primary focus should be on the client’s respiratory status and vital signs. Treating hyperpyrexia would be important if it were present, but it is not typically associated with naloxone administration.

The correct answer is a. The client’s behavioral change is expected after the time period of medication.

Choice A Reason:

This choice is correct because fluoxetine, a selective serotonin reuptake inhibitor (SSRI), typically takes about 4 to 6 weeks to start showing its full effects. The client’s statement, “I feel like a great weight is off my chest,” indicates a positive response to the medication, which aligns with the expected timeline for SSRIs to improve mood and alleviate symptoms of depression. This behavioral change suggests that the medication is working as intended, helping to lift the depressive symptoms.

Choice B Reason:

This choice is incorrect and concerning. While it is true that some individuals may experience a temporary increase in energy before their mood improves, which could potentially increase the risk of suicide, the client’s positive statement does not necessarily indicate suicidal planning. It is important for healthcare providers to continuously monitor for any signs of suicidal ideation, but in this context, the client’s statement more likely reflects an improvement in their depressive symptoms.

Choice C Reason:

This choice is incorrect because there is no indication that the medication dosage should be decreased or that a mood stabilizer should be added. Fluoxetine is generally well-tolerated, and the client’s positive response suggests that the current dosage is effective. Mood stabilizers are typically used in the treatment of bipolar disorder, not major depressive disorder, unless there is a specific indication for their use.

Choice D Reason:

This choice is incorrect and indicates a misunderstanding of serotonin syndrome. Serotonin syndrome is a potentially life-threatening condition caused by excessive serotonin activity in the brain, often due to drug interactions or overdose. Symptoms include agitation, confusion, rapid heart rate, and high blood pressure4. The client’s statement of feeling relieved does not align with the symptoms of serotonin syndrome, which are generally severe and require immediate medical attention.