The client has recently started antidepressant drug therapy. He approaches the nurse complaining of a headache, palpitations, and stiffness in the neck. What is the nurse's priority action?
Give the client two aspirin tablets and monitor his headache and heart rate
Notify the physician immediately
Notify the physician when convenient
Reassure the client that these are common side effects of his medication
The Correct Answer is B
B. This is the correct priority action. Serotonin syndrome can be life-threatening if not promptly recognized and treated. The physician needs to be notified immediately so that appropriate actions can be taken to manage the client's symptoms and potentially adjust the medication regimen.
A. Aspirin is not appropriate for treating serotonin syndrome. Monitoring the client's symptoms is important, but this action does not address the potential seriousness of the symptoms described.
C. Delaying notification could lead to worsening of symptoms and potential complications. Given the potential seriousness of serotonin syndrome, waiting until it's convenient is not appropriate.
D. While headache, palpitations, and stiffness could potentially be side effects of antidepressant medication, the combination of these symptoms raises concern for serotonin syndrome, which requires immediate medical attention rather than reassurance alone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Depersonalization disorder is a dissociative disorder where individuals feel detached from themselves, as if they are observing their own thoughts, feelings, sensations, or actions from outside their body. This can lead to a sense of unreality or detachment from the environment or one's own experiences. It is often triggered by stressful events or trauma, and it can occur in individuals experiencing grief or loss, such as the surviving husband in this scenario.
A. Dissociative fugue involves sudden, unexpected travel away from home or one's customary place of activities, accompanied by an inability to recall one's past. It is usually associated with amnesia for personal information and is not characterized by depersonalization symptoms.
B. DID involves the presence of two or more distinct personality states or identities within an individual, which alternate and take control of behavior. Each identity may have its own unique way of perceiving and interacting with the environment, which differs from the symptoms described in the scenario.
C. Dissociative amnesia involves the inability to recall important personal information, usually related to stressful or traumatic events. While depersonalization symptoms can occur in dissociative amnesia, the hallmark feature is memory loss rather than the feeling of detachment from one's body.
Correct Answer is C
Explanation
C This is a common and potentially life-threatening complication in individuals with anorexia nervosa who are undergoing treatment. It can lead to cardiac arrhythmias.
A. Anorexia nervosa can lead to electrolyte imbalances, including hyponatremia (low serum sodium level), due to inadequate intake of sodium and fluid restriction. Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), can also contribute to hyponatremia by causing the syndrome of inappropriate antidiuretic hormone secretion (SIADH), which leads to water retention and dilutional hyponatremia. However, it is not as life-threatening as hypokalemia.
B. Anorexia nervosa can lead to electrolyte imbalances, including hyponatremia (low serum sodium level), due to inadequate intake of sodium and fluid restriction. However, it is not as life-threatening as hypokalemia.
D. Anorexia nervosa typically does not lead to hyperkalemia (high serum potassium level), as potassium is usually lost through purging behaviors or inadequate intake. Antidepressants also do not commonly cause hyperkalemia as a side effect.
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