A nurse is caring for a client who is prescribed extended-release Morphine. The nurse should recognize which of the following assessment cues as an indication of opioid overdose?

Choice A reason:

Missing a dose of medication that increases serotonin levels does not typically increase the risk of serotonin syndrome. In fact, missing a dose may lead to lower levels of serotonin in the body, which is contrary to the condition of serotonin syndrome that arises from an excess of serotonin.

Choice B reason:

Taking MAOI medication alone does not inherently increase the risk of serotonin syndrome. However, combining MAOIs with other medications that affect serotonin levels can significantly increase the risk. It is crucial to avoid taking MAOIs and other serotonergic drugs concurrently without medical supervision.

Choice C reason:

Taking SNRIs as directed by a healthcare provider generally does not increase the risk of serotonin syndrome. These medications are designed to be taken regularly to manage conditions like anxiety and depression. However, any changes in dosage or frequency should be done under medical guidance to avoid any adverse effects.

Choice D reason:

Combining medications that increase serotonin levels is the primary risk factor for developing serotonin syndrome. This can occur when a patient takes multiple serotonergic drugs, such as combining an SNRI with an SSRI, certain pain medications, or even some over-the-counter drugs and supplements that increase serotonin levels. This combination can lead to an excessive accumulation of serotonin in the body, triggering the symptoms of serotonin syndrome.

Choice A reason:
While it is beneficial for clients to be involved in their care planning, this is not the immediate priority. Active participation in care planning is a goal that can be pursued once the client's safety and stability are ensured.

Choice B reason:
Identifying positive qualities about oneself is an important step in improving self-esteem and promoting recovery in clients with major depressive disorder. However, this is not the most immediate priority when compared to ensuring the client's safety¹.

Choice C reason:
Exhibiting expected grieving behaviors is a natural and necessary process for healing after the loss of a loved one. However, the priority in the acute phase of care, especially when a client is at risk for self-harm, is to ensure safety.

Choice D reason:
The priority nursing goal for a client with major depressive disorder, especially following a significant loss, is to ensure safety. Making a contract to avoid self-harm is a critical intervention that addresses the risk of suicide, which is heightened in individuals with major depressive disorder and recent significant loss. This contract is a verbal or written agreement between the client and the healthcare provider that the client will not harm themselves and will seek help if they have thoughts of self-harm.