The client has recently started antidepressant drug therapy. He approaches the nurse complaining of a headache, palpitations, and stiffness in the neck. What is the nurse's priority action?

Give the client two aspirin tablets and monitor his headache and heart rate

Notify the physician immediately

Notify the physician when convenient

Reassure the client that these are common side effects of his medication

Answer and Explanation

The Correct Answer is B

B. This is the correct priority action. Serotonin syndrome can be life-threatening if not promptly recognized and treated. The physician needs to be notified immediately so that appropriate actions can be taken to manage the client's symptoms and potentially adjust the medication regimen.

A. Aspirin is not appropriate for treating serotonin syndrome. Monitoring the client's symptoms is important, but this action does not address the potential seriousness of the symptoms described.

C. Delaying notification could lead to worsening of symptoms and potential complications. Given the potential seriousness of serotonin syndrome, waiting until it's convenient is not appropriate.

D. While headache, palpitations, and stiffness could potentially be side effects of antidepressant medication, the combination of these symptoms raises concern for serotonin syndrome, which requires immediate medical attention rather than reassurance alone.

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Correct Answer is B

Explanation

B. This stage follows the acute phase of illness and involves efforts to restore functioning, improve quality of life, and regain independence through therapies such as physical therapy, occupational therapy, and speech therapy. Returning to work is a significant milestone in this phase, indicating progress in functional recovery.

A. This stage typically involves initial diagnosis, treatment, and acute management of the illness or condition. It focuses on stabilizing the patient's health and addressing immediate medical needs.

C. This stage emphasizes maintaining health and preventing recurrence or complications once the acute phase and recovery are complete. It involves strategies such as regular check-ups, lifestyle modifications, and adherence to health-promoting behaviors.

D. This stage typically refers to the closure of formal medical or rehabilitative services when the patient no longer requires ongoing professional intervention for the condition.

A. Make a contract with the client for weight gain. B. Initiate one-to-one nursing observation. C. Administer the Hamilton depression scale. D. Review the client's toxicology laboratory report.

Correct Answer is B

Explanation

B. This is the most appropriate initial action. One-to-one observation ensures constant monitoring of the client's safety and prevents further harm, such as another suicide attempt or self-harm. Given the client's history of depression and recent suicide attempt, ensuring their safety is paramount.

A. This option is not the first priority because while addressing anorexia nervosa is important, safety concerns related to the suicide attempt and potential substance abuse take precedence. Making a weight gain contract requires the client's cooperation and readiness, which may not be feasible immediately upon admission.

C. While assessing the severity of depression is crucial, it is secondary to ensuring immediate safety in this context. The client's safety must be established first through continuous observation and intervention.

D. While important to understand the substances involved in the suicide attempt, this action is secondary to ensuring ongoing safety through direct observation. Toxicology results can guide subsequent treatment decisions but are not as urgent as immediate safety measures.

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The client has recently started antidepressant drug therapy. He approaches the nurse complaining of a headache, palpitations, and stiffness in the neck. What is the nurse's priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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