One liter of normal saline is to infuse over 8 hours. At what rate will the nurse set the infusion pump?

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.

The correct answer is b. It’s not my fault.

Choice A Reason: I just don’t remember doing it

This statement might be used by someone trying to avoid responsibility, but it is not as characteristic of antisocial personality disorder (ASPD) as outright denial of fault. Individuals with ASPD often exhibit a lack of accountability and may lie or manipulate to avoid consequences. However, claiming memory loss is less direct than denying responsibility altogether.

Choice B Reason: It’s not my fault

This statement is highly characteristic of antisocial personality disorder. Individuals with ASPD often refuse to take responsibility for their actions and may blame others or external circumstances. This lack of accountability and tendency to deflect blame is a core feature of the disorder, making this the most expected comment.

Choice C Reason: I’m really sorry about all the people I’ve hurt

This statement is unlikely for someone with antisocial personality disorder. People with ASPD typically lack empathy and remorse for their actions. Expressing genuine sorrow and concern for others is not consistent with the typical behavior of someone with this disorder.

Choice D Reason: I’m too ashamed to talk about it

This statement suggests a level of self-awareness and guilt that is not typical of antisocial personality disorder. Individuals with ASPD generally do not experience shame or guilt in the same way as others. They are more likely to be indifferent or dismissive about the consequences of their actions.