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. Daytime naps can interfere with the natural sleep-wake cycle, potentially causing fragmented nighttime sleep. Disrupted nighttime sleep increases the likelihood of wandering and confusion in clients with Alzheimer’s disease.
B. Installing locks at the bottom of exit doors can prevent the client from leaving unsupervised. However, this may also pose a risk of entrapment or delay emergency egress, which can compromise overall safety.
C. Placing the mattress on the floor reduces the height from which the client could fall, decreasing the risk of injury during nighttime wandering. This intervention directly addresses the physical safety of clients prone to getting out of bed at night.
D. Rubber-backed throw rugs can create uneven surfaces that increase the risk of tripping or slipping. For clients with impaired judgment or mobility, these rugs can inadvertently raise the chance of falls rather than prevent them.
Correct Answer is C
Explanation
A. "We will help get you through this. You'll be fine.": While this statement may be meant to comfort, it dismisses the client's feelings and doesn't address the possibility of immediate harm or crisis. It’s important to validate the client’s emotions and assess for safety.
B. "What have you done to change your situation?": This response can come across as accusatory or judgmental, which may not be helpful in a crisis situation. It’s important to be supportive and nonjudgmental rather than questioning the client’s actions.
C. "Are you thinking about harming yourself?": The client's statement indicates feelings of hopelessness, which could signal suicidal ideation. Directly asking about self-harm or suicide helps assess the client's safety and provides an opportunity to intervene if necessary.
D. "You should remove yourself from this situation now.": While suggesting safety is important, this statement may feel too directive or overwhelming. The nurse should assess the client’s readiness for action and help them explore their options in a supportive way.
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