A nurse is teaching a client who has a new prescription for sertraline 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.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Insomnia is a common side effect of sertraline and many other antidepressant medications. It is not indicative of serotonin syndrome, a potentially life-threatening condition characterized by excessive serotonin levels in the brain.

Choice B rationale:

Constipation is a side effect of some antidepressant medications, including sertraline. It is not a symptom of serotonin syndrome, which presents with a combination of symptoms such as confusion, agitation, rapid heart rate, dilated pupils, muscle rigidity, and high body temperature.

Choice C rationale:

Dry mouth is another common side effect of sertraline and many other medications. While uncomfortable, it is not a sign of serotonin syndrome. Symptoms of serotonin syndrome are neurological and autonomic, involving changes in mental status, muscle activity, and vital signs.

Choice D rationale:

Excessive sweating, also known as diaphoresis, can be a symptom of serotonin syndrome. Other symptoms might include agitation, tremor, hyperreflexia, fever, dilated pupils, and diarrhea. If a patient experiences these symptoms while taking sertraline, it could indicate serotonin syndrome and should be reported immediately for medical evaluation.

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Correct Answer is B

Explanation

Allow for frequent rest periods throughout the day.

A. Perform ADLs for the client to promote rest. This is incorrect because performing ADLs for the client can increase their dependence and decrease their self-esteem. The nurse should encourage the client to perform ADLs as much as possible, with assistance as needed, to maintain their function and mobility.
B. Allow for frequent rest periods throughout the day. This is correct because rest periods can help reduce fatigue and pain, as well as prevent joint damage and inflammation. The nurse should balance rest and activity for the client and avoid overexertion.
C. Use heat to reduce joint inflammation. This is incorrect because heat can increase inflammation and pain in acute rheumatoid arthritis. The nurse should use cold applications to reduce swelling and inflammation in acute episodes, and use heat for chronic stiffness and pain. - D. Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain. This is incorrect because acetaminophen has a maximum daily dose of 4 g/day, and exceeding this dose can cause liver toxicity. The nurse should monitor the client's liver function and use other analgesics as prescribed.

A. The child exhibits discomfort while walking B. The child has thin extremities C. The child has bruises on the upper back D. The child is wearing a stained shirt

Correct Answer is A

Explanation

A - This is correct because discomfort while walking can indicate genital trauma or infection, which are possible signs of sexual abuse.

B - This is incorrect because thin extremities can be caused by many factors, such as malnutrition, genetic disorders, or chronic diseases, that are not necessarily related to sexual abuse.

C - This is incorrect because bruises on the upper back can result from accidental injuries, such as falls or bumps, or from physical abuse, such as hitting or kicking, but not specifically from sexual abuse.

D - This is incorrect because a stained shirt can be due to poor hygiene, food spills, or environmental factors, but not necessarily from sexual abuse.

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A nurse is teaching a client who has a new prescription for sertraline to treat depression.For which of the following findings should the nurse instruct the client to monitor and report immediately as indicating serotonin syndrome?

Nursing Test Bank

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A nurse is teaching a client who has a new prescription for sertraline to treat depression.
For which of the following findings should the nurse instruct the client to monitor and report immediately as indicating serotonin syndrome?