The nurse is continuing to care for the client in the emergency department (ED). 

Exhibits

The nurse should monitor the client for which of the following based on the result of the client's laboratory test? Select all that apply.

A. Decrease in blood pressure: A decrease in blood pressure is a positive sign that the treatment for serotonin syndrome is effective. Treatment typically includes discontinuing the causative medication and providing supportive care to normalize vital signs, including blood pressure.

B. Muscle rigidity: Muscle rigidity is a hallmark sign of serotonin syndrome and indicates that the condition is still present or not yet effectively treated. Successful treatment should reduce muscle rigidity over time.

C. Hyperreflexia: Hyperreflexia (overactive reflexes) is also a common symptom of serotonin syndrome. If the treatment is effective, hyperreflexia should resolve as serotonin levels normalize in the body.

D. Altered mental status: Altered mental status is another indicator of serotonin syndrome. Improvement in serotonin syndrome would be evidenced by a return to normal cognitive function, so persistence of altered mental status suggests that treatment has not yet been fully effective.

Rationale for correct choices:

• Remaining neutral: The nurse should remain neutral to avoid reinforcing or escalating the client’s grandiose beliefs. This helps maintain trust and creates space for self-reflection without judgment.
• Explaining that the client is not entitled to play on a professional team: Gently addressing the client’s unrealistic expectations helps them understand the reality of their situation and fosters a more grounded perspective on their goals.

Rationale for incorrect choices:

• Questioning the client's abilities: Directly questioning the client's abilities could be seen as confrontational and may increase defensiveness. A more constructive approach would focus on challenging unrealistic beliefs.
• Challenging the client's feelings of grandiosity: Challenging grandiosity directly can make the client feel attacked. It’s better to educate and explain the reality of their expectations in a supportive way.
• Supporting the client's fear of abandonment: The client does not appear to express abandonment fears in this case. The issue is more related to grandiosity, so focusing on this would be more effective.
• Suggesting another sport: Suggesting a different sport might divert attention from the core issue—grandiosity. Addressing the client's distorted self-image is more important before offering alternatives.