A client has been taking Sertraline for the past 2 days. Which of the following assessment findings should alert the nurse to the possibility that the client is developing Serotonin syndrome?

Correct Answer: B

Rationale: Fever is a key symptom of serotonin syndrome, a potentially serious condition that can occur with the use of SSRIs like Sertraline. Serotonin syndrome is characterized by excessive levels of serotonin in the body, leading to symptoms such as fever, agitation, confusion, tremors, and sweating. If a client on Sertraline presents with fever, the nurse should consider the possibility of serotonin syndrome and take appropriate actions such as notifying the healthcare provider and monitoring the client closely.

Correct Answer: B

Rationale: Liver damage is an adverse effect of Atomoxetine. The nurse should monitor for manifestations such as jaundice, upper abdominal tenderness, darkening of urine, and elevated liver enzymes. It is crucial to be vigilant for signs of liver damage to ensure early detection and intervention to prevent further complications.

Correct Answer: D

Rationale: In this scenario, the priority action for the nurse is to obtain baseline vital signs. This is crucial for establishing a baseline assessment, especially for a patient undergoing opioid withdrawal and starting a new medication like Clonidine. Monitoring vital signs is essential for evaluating the patient's response to treatment and detecting any potential complications early on.

Correct Answer: D

Rationale: In this scenario, the correct answer is option D) Yellow-tinged vision. Digoxin is a medication commonly used to treat heart failure, but it can have serious adverse effects if not monitored closely. Yellow-tinged vision is a classic sign of digoxin toxicity and should be reported to the healthcare provider immediately. This visual disturbance can indicate that the digoxin levels in the body are too high, potentially leading to life-threatening cardiac arrhythmias. Option A) Dry cough is not typically associated with digoxin use. Dry cough is more commonly seen with medications like ACE inhibitors used to treat conditions like hypertension. Option B) Pedal edema is a frequent symptom of heart failure itself and may not necessarily be directly related to digoxin use. It is crucial to monitor for changes in pedal edema, but it is not a specific adverse effect of digoxin. Option C) Bruising is also not a typical adverse effect of digoxin. Bruising may occur due to various reasons such as trauma or underlying clotting disorders, but it is not directly linked to digoxin use. Educationally, this question highlights the importance of understanding the specific adverse effects of medications, especially those commonly used in managing chronic conditions like heart failure. It emphasizes the need for close monitoring and timely reporting of any unusual symptoms to prevent serious complications in patient care.

Correct Answer: C

Rationale: Rationale: Correct Answer: C) I will increase my intake of foods high in potassium. Explanation: This statement indicates a need for further teaching because Warfarin is a vitamin K antagonist, not potassium. Increasing potassium intake can potentially interfere with the anticoagulant effects of Warfarin, leading to ineffective treatment and increased risk of clotting. Option A: Avoiding large amounts of green leafy vegetables is correct because they are high in vitamin K, which can interfere with the effects of Warfarin. This statement shows the client understands the dietary restrictions necessary while on Warfarin therapy. Option B: Taking medication at the same time every day is important for maintaining consistent blood levels of Warfarin and ensuring its effectiveness. This statement demonstrates good medication adherence practice. Option D: Reporting any signs of bleeding to the provider is crucial when on Warfarin as it can increase the risk of bleeding. This statement indicates the client's understanding of a potential side effect and the importance of timely reporting to healthcare providers. Educational Context: Understanding the dietary restrictions, medication adherence, and potential side effects of Warfarin is essential for clients to manage their therapy effectively and prevent complications. Providing accurate and comprehensive education empowers clients to take an active role in their healthcare and promotes safe medication use.