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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Lithium is excreted primarily by the kidneys, and its clearance can be affected by changes in fluid balance. It's important for clients taking lithium to maintain a stable and adequate fluid intake to help regulate lithium levels in the body. Stable fluid intake helps maintain electrolyte balance, which is crucial for the proper function of lithium and prevention of adverse effects.

B. Lithium can affect sodium reabsorption in the kidneys. High levels of sodium intake can alter lithium levels in the body, potentially leading to toxicity. Therefore, clients on lithium therapy are often advised to maintain a consistent and moderate level of sodium intake. Excessive dietary salt can interfere with lithium's therapeutic effects.

C. Restricting fluid intake is not recommended unless there are specific medical reasons to do so. Lithium therapy generally requires adequate hydration to maintain kidney function and prevent dehydration, which can affect lithium levels.

D. Exercising in hot weather can lead to increased sweating and fluid loss, which can potentially affect lithium levels by altering hydration status. However, the primary concern during exercise in hot weather is maintaining adequate hydration rather than restricting it.

A. Medical care B. Recovery and rehabilitation C. Wellness care D. Termination of care

Correct Answer is B

Explanation

B. This stage follows the acute phase of illness and involves efforts to restore functioning, improve quality of life, and regain independence through therapies such as physical therapy, occupational therapy, and speech therapy. Returning to work is a significant milestone in this phase, indicating progress in functional recovery.

A. This stage typically involves initial diagnosis, treatment, and acute management of the illness or condition. It focuses on stabilizing the patient's health and addressing immediate medical needs.

C. This stage emphasizes maintaining health and preventing recurrence or complications once the acute phase and recovery are complete. It involves strategies such as regular check-ups, lifestyle modifications, and adherence to health-promoting behaviors.

D. This stage typically refers to the closure of formal medical or rehabilitative services when the patient no longer requires ongoing professional intervention for the condition.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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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?