The nurse is providing care to a client diagnosed with schizophrenia and is experiencing anticholinergic side effects from long-term use of typical antipsychotics. Which of the following symptoms would the nurse expect to see during an assessment?

Choice A reason: St. John’s Wort with sertraline increases serotonin levels, risking serotonin syndrome. Symptoms like diaphoresis, tachycardia, and tremors are classic signs, requiring urgent monitoring, making this the correct observation for the client.

Choice B reason: Fever, dystonia, and muscle rigidity suggest neuroleptic malignant syndrome, linked to antipsychotics, not sertraline or St. John’s Wort. This is unrelated to the drug interaction, making it incorrect.

Choice C reason: Worsening depression or suicidal ideation may occur with antidepressants, but St. John’s Wort more likely causes serotonin syndrome. These symptoms are less immediate, making this incorrect for the primary concern.

Choice D reason: Spasms and bizarre movements suggest tardive dyskinesia, associated with antipsychotics, not sertraline or St. John’s Wort. Serotonin syndrome is the primary risk, making this incorrect.

Choice A reason: Gathering seizure history from the spouse provides valuable information for long-term management, such as identifying triggers or medication history. However, during an active seizure lasting 10 minutes, the priority is to stop the seizure to prevent status epilepticus, which can cause brain damage due to prolonged neuronal hyperactivity and hypoxia, making history collection secondary.

Choice B reason: Checking glucose levels is relevant in cases where hypoglycemia may trigger seizures, as low blood sugar can disrupt neuronal function. However, during an active, prolonged seizure, the immediate priority is terminating the seizure to prevent cerebral hypoxia and neuronal injury. Glucose checks can follow after the seizure is controlled to identify underlying causes.

Choice C reason: Applying soft wrist restraints may reduce injury risk by limiting movement during a seizure. However, this does not address the underlying neuronal hyperactivity causing the seizure. Prolonged seizures (over 5 minutes) risk brain damage or systemic complications, so administering anticonvulsants to stop the seizure takes precedence over restraint application.

Choice D reason: Establishing IV access and administering lorazepam is the priority for a patient seizing for 10 minutes. Lorazepam, a benzodiazepine, enhances GABA-mediated inhibition in the brain, rapidly terminating seizure activity. This prevents status epilepticus, a life-threatening condition causing neuronal damage, hypoxia, or death if untreated, making it the most critical intervention in this scenario.