A nurse is caring for a client who reports that they have been eliminating specific foods from their diet in order to “eat clean.” The nurse should identify that this is an indication of which of the following conditions?

The correct answer is a. The client’s behavioral change is expected after the time period of medication.

Choice A Reason:

This choice is correct because fluoxetine, a selective serotonin reuptake inhibitor (SSRI), typically takes about 4 to 6 weeks to start showing its full effects. The client’s statement, “I feel like a great weight is off my chest,” indicates a positive response to the medication, which aligns with the expected timeline for SSRIs to improve mood and alleviate symptoms of depression. This behavioral change suggests that the medication is working as intended, helping to lift the depressive symptoms.

Choice B Reason:

This choice is incorrect and concerning. While it is true that some individuals may experience a temporary increase in energy before their mood improves, which could potentially increase the risk of suicide, the client’s positive statement does not necessarily indicate suicidal planning. It is important for healthcare providers to continuously monitor for any signs of suicidal ideation, but in this context, the client’s statement more likely reflects an improvement in their depressive symptoms.

Choice C Reason:

This choice is incorrect because there is no indication that the medication dosage should be decreased or that a mood stabilizer should be added. Fluoxetine is generally well-tolerated, and the client’s positive response suggests that the current dosage is effective. Mood stabilizers are typically used in the treatment of bipolar disorder, not major depressive disorder, unless there is a specific indication for their use.

Choice D Reason:

This choice is incorrect and indicates a misunderstanding of serotonin syndrome. Serotonin syndrome is a potentially life-threatening condition caused by excessive serotonin activity in the brain, often due to drug interactions or overdose. Symptoms include agitation, confusion, rapid heart rate, and high blood pressure4. The client’s statement of feeling relieved does not align with the symptoms of serotonin syndrome, which are generally severe and require immediate medical attention.

Choice A Reason: Notify all members of the treatment team and place the client on suicide precautions

While notifying the treatment team and placing the client on suicide precautions is crucial, it is not the immediate priority. The first step is to assess the immediacy and severity of the risk by determining if the client has a specific plan. This assessment helps in understanding the level of danger and urgency required in the intervention.

Choice B Reason: Assess for past history of suicide attempts

Assessing for a past history of suicide attempts is important for understanding the client’s risk factors and potential for future attempts. However, it is not the immediate priority when a client expresses current suicidal ideation. The immediate concern is to assess the current risk and plan, which directly impacts the urgency of the intervention.

Choice C Reason: Identify coping mechanisms

Identifying coping mechanisms is a valuable part of the overall treatment plan and can help in long-term management. However, in the context of immediate suicidal ideation, the priority is to assess the current risk and plan. Once the immediate risk is managed, coping mechanisms can be explored to support the client’s ongoing mental health.

Choice D Reason: Determine whether the client has a specific plan to commit suicide

This is the correct answer. Determining whether the client has a specific plan to commit suicide is the highest priority because it directly assesses the immediacy and severity of the risk. If the client has a specific plan, it indicates a higher level of danger and necessitates immediate intervention to ensure the client’s safety.