The practical nurse assesses a client who is receiving carbamazepine for a seizure disorder. The client reports the onset of a sore throat. Which additional assessment data should the PN obtain before reporting to the charge nurse?

Choice A reason: Restlessness, tachycardia, fever, and hypertension suggest serotonin syndrome, a life-threatening paroxetine side effect due to excessive serotonin. Withholding the dose and contacting the provider prevents further serotonin accumulation, allowing urgent assessment and intervention to stabilize the client’s neurological and cardiovascular status.

Choice B reason: A cooling blanket addresses fever but is not the first action for serotonin syndrome. Withholding paroxetine and consulting the provider are critical to stop the syndrome’s progression, as fever is a symptom, not the cause, making this choice secondary to halting the drug.

Choice C reason: Taking the client to a quiet area may reduce stimulation but does not address serotonin syndrome’s physiological cause. Paroxetine’s serotonin excess drives symptoms, requiring drug cessation and medical intervention, not just reassurance, as this condition can rapidly worsen, making this choice inadequate.

Choice D reason: Administering benzodiazepine and acetaminophen is premature without provider guidance, as serotonin syndrome requires specific treatments, like cyproheptadine. Paroxetine must be stopped first, and the provider consulted to confirm diagnosis and manage symptoms, making this choice unsafe and reactive.

Choice A reason: A neurological exam assesses brain function but does not directly address glipizide-related symptoms like confusion and blurred vision, which suggest hypoglycemia. Glipizide, a sulfonylurea, lowers blood glucose, and these symptoms are likely due to low glucose levels, making glucose testing more urgent than a neurological evaluation.

Choice B reason: Administering glucagon treats severe hypoglycemia but is premature without confirming low blood glucose. Glipizide increases insulin release, potentially causing hypoglycemia, but a fingerstick glucose test is needed first to verify the cause of symptoms. This choice is incorrect without diagnostic confirmation.

Choice C reason: Measuring vital signs provides general health data but does not specifically address confusion and blurred vision caused by glipizide-induced hypoglycemia. Low blood glucose is the likely cause, and testing glucose levels is more direct and urgent than monitoring vital signs, which are secondary in this context.

Choice D reason: Obtaining a fingerstick blood glucose is critical, as glipizide can cause hypoglycemia, leading to confusion and blurred vision. These symptoms result from insufficient glucose in the brain and eyes. Confirming low glucose guides immediate treatment, such as glucose administration, making this the most appropriate action.