A nurse is caring for a client who started the SSRI fluoxetine 3 days ago and now reports feeling agitated, with muscle tremors and a temperature of 39°C (102.2°F). Upon assessment, the nurse notes hyperreflexia, tremors, and diaphoresis. What is the nurse's best initial action?

Administer acetaminophen for the fever and continue to monitor the client.

increase the client's fluid intake to prevent dehydration and recheck vital signs in one hour.

Notify the provider immediately to evaluate for serotonin syndrome and initiate treatment.

Encourage the client to rest and provide a cooling blanket to reduce the fever

Answer and Explanation

The Correct Answer is C

A. Administer acetaminophen for the fever and continue to monitor the client: Fever associated with serotonin syndrome is caused by neuromuscular hyperactivity, not infection or inflammation. Acetaminophen will not correct the underlying cause and delays definitive treatment. Immediate escalation of care is required.

B. Increase the client's fluid intake to prevent dehydration and recheck vital signs in one hour: Hydration alone is insufficient in the presence of agitation, hyperreflexia, tremors, and hyperthermia. Waiting an hour risks rapid clinical deterioration. These findings require urgent medical intervention, not delayed reassessment.

C. Notify the provider immediately to evaluate for serotonin syndrome and initiate treatment: Recent initiation of fluoxetine combined with hyperthermia, agitation, hyperreflexia, tremors, and diaphoresis strongly suggests serotonin syndrome. This is a medical emergency requiring immediate discontinuation of serotonergic agents and supportive or pharmacologic treatment.

D. Encourage the client to rest and provide a cooling blanket to reduce the fever: Cooling measures may be part of supportive management but are not sufficient as an initial nursing response. Without provider notification and treatment, symptoms may progress to seizures, arrhythmias, or death.

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Correct Answer is B

Explanation

A. “I’m glad to hear that. Keep the remaining medication in case your symptoms come back.”Stopping the medication early can prevent full healing and may lead to symptom recurrence or incomplete treatment of the underlying condition. Keeping leftover medication without completing the course is unsafe.

B. “I’m glad to hear that. Continue with your medication until it is all done. We can set a follow-up appointment next month.”Completing the prescribed course ensures adequate healing of gastric or duodenal ulcers and reduces the risk of recurrence. Scheduling follow-up allows assessment of treatment effectiveness and monitoring for side effects.

C. "I'm glad to hear that. Go ahead and discontinue the medication and schedule a follow-up for next month."Discontinuing the medication early, even if symptoms have resolved, can result in incomplete treatment and possible recurrence of ulcers or acid-related issues. Continuing the full course is necessary.

D. "I'm glad to hear that. You should be clear to reintroduce all the food items we eliminated during your treatment."Dietary modifications are individualized. Abruptly reintroducing all restricted foods without guidance may trigger symptom recurrence. Education should include gradual reintroduction and monitoring tolerance.

A. "Avoid driving anywhere until you know how the medication affects you” B. "Combine this medication with some codeine to enhance the pain killing effects." C. "If the first dose doesn't work after 30 minutes, take a second dose” D. "If you get drowsy, drink some coffee to stay awake”

Correct Answer is A

Explanation

A. "Avoid driving anywhere until you know how the medication affects you":Baclofen is a centrally acting muscle relaxant that can cause drowsiness, dizziness, and impaired coordination. Patients should avoid activities requiring alertness, such as driving, until they understand how the medication affects them.

B. "Combine this medication with some codeine to enhance the pain-killing effects":Combining baclofen with other CNS depressants like codeine increases the risk of excessive sedation and respiratory depression. Concurrent use should only occur under direct provider guidance.

C. "If the first dose doesn't work after 30 minutes, take a second dose":Baclofen dosing should follow the prescribed schedule. Taking extra doses without guidance can lead to overdose, severe drowsiness, or hypotension.

D. "If you get drowsy, drink some coffee to stay awake":Attempting to counteract CNS depression with caffeine does not safely mitigate baclofen’s sedative effects. The priority is to adjust activities and avoid situations that require alertness, not to override drowsiness with stimulants.

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A nurse is caring for a client who started the SSRI fluoxetine 3 days ago and now reports feeling agitated, with muscle tremors and a temperature of 39°C (102.2°F). Upon assessment, the nurse notes hyperreflexia, tremors, and diaphoresis. What is the nurse's best initial action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Your patient is reporting a complete resolution of his symptoms 3 weeks after starting the H2 antagonist medication, cimetidine. His prescription is for 4 weeks of treatment, Which statement best reflects what the nurse's instructions should be?

Correct Answer is B

Explanation

A patient is prescribed the centrally acting muscle relaxant baclofen. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

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