A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of the following is the priority nursing intervention?

Padding side rails to prevent injury.

Applying a cooling blanket.

Administering an anticonvulsant.

Preparing for artificial ventilation.

Answer and Explanation

The Correct Answer is D

While preventing injury is important, it is not the highest priority when the client's respiratory and neurological functions are compromised. Managing the client's breathing takes precedence.

B. Applying a cooling blanket.

While hyperthermia (high fever) is a symptom of serotonin syndrome, the immediate concern is ensuring the client's breathing and neurological stability. Cooling measures can be beneficial, but they come after addressing the more critical issues.

C. Administering an anticonvulsant.

While anticonvulsants might be used to control seizures, preparing for artificial ventilation takes priority, as the client's airway and oxygenation must be secured before addressing other symptoms.

D. Preparing for artificial ventilation.

Explanation: Serotonin syndrome is a potentially life-threatening condition caused by an excess of serotonin in the body, often resulting from interactions between medications that affect serotonin levels. Severe manifestations of serotonin syndrome can include high fever, muscle rigidity, agitation, seizures, and even coma. In cases of severe serotonin syndrome, the client's neurological and respiratory functions can be compromised, making it crucial to ensure adequate ventilation and oxygenation.

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Correct Answer is C

Explanation

While offering female assistive personnel for personal hygiene care is one option, it doesn't necessarily address the larger concern of the client's discomfort with a male nurse in her care team. The nurse manager's response should address the client's overall care and interactions.

B) "Your doctor is a man, so it seems like this should not be a problem."

Comparing the client's situation to the gender of the doctor might not be perceived as sensitive or supportive. The client's comfort with different members of the care team can vary, and it's important to address her concerns directly.

C) "I can review the assignments and arrange for a female nurse to care for you."

Explanation:

Respecting a patient's preferences and comfort is an important aspect of patient-centered care. If the female client expresses discomfort with a male nurse providing care due to her traumatic experience, it's appropriate for the nurse manager to accommodate her request if feasible. Changing the assignment to ensure that a female nurse provides care respects the client's wishes and helps create a more supportive and comfortable environment.

D) "The nurse assigned to care for you is very capable and cares for other women in this situation."

While it's important to emphasize the capabilities of the nurse, this response does not directly address the client's expressed discomfort with a male nurse. It's crucial to prioritize the client's feelings and concerns in this situation.

A. A client runs 4 miles outdoors every afternoon. B. The client eats 2 to 3 gm of sodium-containing foods daily. C. The client drinks 2 liters of liquids daily. D. The client eats foods high in tyramine.

Correct Answer is A

Explanation

A.Lithium is excreted through the kidneys, and dehydration and sodium depletion increase the risk of lithium toxicity. A client who runs 4 miles outdoors every afternoon is at risk of excessive sweating and fluid loss, which can lead to dehydration and sodium depletion. This reduces lithium excretion, leading to toxic levels in the blood.

B. Anormal sodium intake helps maintain lithium balance. A low sodium intake increases lithium retention, but 2-3 grams/day is within the normal recommended range.

C. Adequate hydration helps prevent lithium toxicity. Clients on lithium should drink 2–3 liters of fluid daily to promote kidney function and lithium excretion.
D. Tyramine-rich foods (e.g., aged cheese, cured meats) are a concern for clients on monoamine oxidase inhibitors (MAOIs), not lithium. Tyramine does not affect lithium levels.

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A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of the following is the priority nursing intervention?

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Correct Answer is C

Explanation

A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse could teach the client which of the following factors puts her at risk for lithium toxicity?

Correct Answer is A

Explanation

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