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 C
Explanation
C Somatoform disorders are characterized by physical symptoms that suggest a medical condition but cannot be fully explained by a general medical condition, another mental disorder, or substance use. Individuals with somatoform disorders often experience distress or impairment due to these symptoms despite medical reassurance that no physical cause can be found.
A. Dysthymia is a type of persistent depressive disorder characterized by a depressed mood that lasts for at least two years. It typically involves emotional and behavioral symptoms rather than physical symptoms without clinical findings.
B. Body dysmorphic disorder involves a preoccupation with perceived defects or flaws in physical appearance that are not observable or appear slight to others. While it involves body image concerns, it does not manifest as physical symptoms in the absence of objective findings.
D. Major depressive disorder primarily involves mood disturbances such as sadness, loss of interest or pleasure, and changes in appetite or sleep. While physical symptoms like fatigue and changes in weight can occur, they are not typically reported persistently without objective clinical findings as seen in somatoform disorders.
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.
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