A nurse is assessing a client following treatment for serotonin syndrome caused by an antidepressant medication. Which of the following findings indicates the treatment has been effective?
Decrease in blood pressure
Muscle rigidity
Нуреrreflexia
Altered mental status
The Correct Answer is A
A. Decrease in blood pressure: A decrease in blood pressure is a positive sign that the treatment for serotonin syndrome is effective. Treatment typically includes discontinuing the causative medication and providing supportive care to normalize vital signs, including blood pressure.
B. Muscle rigidity: Muscle rigidity is a hallmark sign of serotonin syndrome and indicates that the condition is still present or not yet effectively treated. Successful treatment should reduce muscle rigidity over time.
C. Hyperreflexia: Hyperreflexia (overactive reflexes) is also a common symptom of serotonin syndrome. If the treatment is effective, hyperreflexia should resolve as serotonin levels normalize in the body.
D. Altered mental status: Altered mental status is another indicator of serotonin syndrome. Improvement in serotonin syndrome would be evidenced by a return to normal cognitive function, so persistence of altered mental status suggests that treatment has not yet been fully effective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. High self-esteem: High self-esteem is not a risk factor for alcohol use disorder. In fact, individuals with alcohol use disorder often struggle with low self-esteem and emotional distress.
B. Low socioeconomic status: While low socioeconomic status can be a risk factor for various mental health and substance use issues, it is not as directly linked to alcohol use disorder as other factors, such as genetics or environmental influences.
C. Genetic predisposition: Genetic predisposition is a significant risk factor for alcohol use disorder. Family history and genetic factors can influence the likelihood of developing alcohol use disorder, making it a key factor to include in the presentation.
D. History of maternal infection during pregnancy: While maternal infections during pregnancy can have various effects on fetal development, they are not directly linked to the development of alcohol use disorder.
Correct Answer is C
Explanation
A. Secure the client in bed by tightly tucking in sheets: Tightly tucking sheets is not an appropriate use of restraints and may increase the risk of injury. Restraints should be applied according to proper guidelines, and they should allow the client to move as much as is safe.
B. Obtain a prescription to renew the restraint prescription every 48 hr: Restraint prescriptions must be renewed every 24 hours, not every 48 hours, to ensure ongoing assessment of the client's need for restraints.
C. Document the interventions used before applying restraints: It is important to document all interventions attempted before applying restraints. This includes any less restrictive measures that were tried and failed before restraints were applied, in line with best practices and legal requirements.
D. Delegate assistive personnel to check on the client regularly: While assistive personnel can help with monitoring, the nurse is ultimately responsible for ensuring the client is checked on regularly and for assessing the safety and well-being of the client in restraints.
Complete the following sentence by using the lists of options.
The client is at risk of developing