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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
- A is correct because aPTT (activated partial thromboplastin time) measures the effectiveness of heparin therapy and guides dosage adjustments.
- B is incorrect because PT (prothrombin time) measures the effectiveness of warfarin therapy, not heparin.
- C is incorrect because INR (international normalized ratio) is a standardized version of PT that also monitors warfarin therapy, not heparin.
- D is incorrect because WBC count (white blood cell count) measures the body's immune response and has no relation to heparin therapy.
Correct Answer is D
Explanation
Choice A rationale:
Instructing the client to "Lie down for 30 min after meals" is an inappropriate recommendation for managing heartburn during pregnancy. Lying down after meals allows stomach acid from flowing back into the esophagus, worseningheartburn symptoms.
Choice B rationale:
Eating a high-fat snack at bedtime is not advisable for managing heartburn. Fatty foods can relax the lower esophageal sphincter, allowing stomach acid to flow back into the esophagus and worsen heartburn symptoms. Avoiding high-fat snacks close to bedtime is a more appropriate recommendation.
Choice C rationale:
Sipping carbonated beverages throughout the day can exacerbate heartburn symptoms. Carbonated beverages, including sodas and sparkling water, can increase stomach acid and contribute to heartburn. Therefore, advising the client to avoid carbonated beverages is more appropriate for managing heartburn during pregnancy.
Choice D rationale:
Drinking hot herbal tea alleviates the heartburn symptoms and is recommended in pregnancy.
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