A nurse is teaching a client who has a new prescription for sertralihe to treat depression. For which of the following findings should the nurse instruct the client to monitor and report immediately as indicating serotonin syndrome?
Insomnia
Constipation
Dry mouth
Excessive sweating
The Correct Answer is D
A. Insomnia: While insomnia can be a side effect of sertraline, it is not typically associated with serotonin syndrome. However, if the insomnia is severe or accompanied by other symptoms of serotonin syndrome, it should be reported to the healthcare provider.
B. Constipation: Constipation is a common side effect of sertraline but is not indicative of serotonin syndrome. It is important to monitor for constipation and manage it appropriately but not as an indicator of serotonin syndrome.
C. Dry mouth: Dry mouth is another common side effect of sertraline but is not specific to serotonin syndrome. While uncomfortable, it does not typically require immediate reporting unless severe or accompanied by other concerning symptoms.
D. Excessive sweating: Excessive sweating, also known as diaphoresis, is a hallmark symptom of serotonin syndrome. It is a significant indicator of serotonin toxicity and should be reported immediately to the healthcare provider for further evaluation and management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Answer: B
Rationale:
A) Activate the fire alarm system:
While activating the fire alarm system is essential in alerting everyone to the fire, the immediate safety of the clients must be prioritized first. Ensuring clients are safe from potential harm should precede alerting others.
B) Evacuate clients from the area:
Evacuating clients from the area is the first priority as it directly ensures their safety. In the event of a fire, removing individuals from the source of danger is crucial to prevent injury or harm.
C) Obtain and use a fire extinguisher:
Using a fire extinguisher to put out the fire is important, but it should not be the first action. Ensuring clients are evacuated to safety must take precedence before attempting to control the fire.
D) Close the doors and windows on the unit:
Closing doors and windows can help contain the fire and smoke, but this should follow the evacuation of clients. The primary concern is to get clients to a safe area first before taking measures to contain the fire.
Correct Answer is B
Explanation
A. "Incident report completed. A copy will be placed in the client's medical record." This statement indicates the completion of the incident report but lacks essential information about what incident occurred. It does not provide details necessary for understanding the nature of the incident.
B. "Prescribed dressing change was accidentally omitted during the previous shift." This statement clearly identifies the nature of the incident, stating that a prescribed dressing change was missed. It provides factual information without assigning blame, which is appropriate for an incident report.
C. "A nurse accidentally omitted a prescribed dressing change. Will notify the provider tomorrow." While this statement acknowledges the omission, it lacks details about the incident and focuses on future actions rather than accurately documenting what occurred.
D. "Unable to complete a prescribed dressing change. However, dressing did not appear to be soiled." This statement does not accurately represent the situation. It implies that the dressing change was not completed due to the dressing not appearing soiled, which may not be the case. It does not acknowledge the omission of the prescribed dressing change.
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