A nurse is assessing a client who takes citalopram to treat depression. Which of the following findings should the nurse identify as an indication of serotonin syndrome?
Muscle rigidity
Constipation
Lethargy
Bradycardia
The Correct Answer is A
Choice A reason: Muscle rigidity is a hallmark symptom of serotonin syndrome, often accompanied by hyperreflexia, tremors, and autonomic instability. It requires immediate intervention.
Choice B reason: Constipation is not associated with serotonin syndrome. It may be a side effect of other medications but is not diagnostic.
Choice C reason: Lethargy is nonspecific and may occur in many conditions. Serotonin syndrome typically presents with agitation and hyperactivity rather than sedation.
Choice D reason: Bradycardia is not typical of serotonin syndrome. Tachycardia and hypertension are more common due to autonomic dysregulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Failure to administer prescribed medication is a medication error and must be documented through an incident report. This ensures accountability, promotes safety, and initiates corrective action to prevent recurrence.
Choice B reason: Aggressive behavior may be part of the client’s psychiatric presentation. Unless it results in harm or requires emergency intervention, it may not meet the threshold for an incident report unless facility policy dictates otherwise.
Choice C reason: Missing a therapy session is not typically considered an incident unless it results in harm or is part of a pattern requiring intervention. It should be documented in progress notes, not an incident report.
Choice D reason: Refusal to leave the room may indicate worsening depression but does not constitute an incident unless it leads to harm or safety concerns. It should be addressed in the care plan.
Correct Answer is D
Explanation
Choice A reason: Progressive muscle relaxation may help reduce anxiety, but it requires a level of cognitive and emotional awareness that may be challenging for children with autism who struggle with emotional expression.
Choice B reason: Guided imagery is a cognitive strategy that may be difficult for children with autism due to challenges with abstract thinking and imagination.
Choice C reason: Extended play sessions with peers may be overwhelming or counterproductive for children with autism, especially if they have difficulty with social reciprocity or sensory processing.
Choice D reason: Art therapy is a developmentally appropriate and evidence-based intervention that allows children with autism to express emotions nonverbally, supporting emotional regulation and communication.
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