A, C, D, E
Rationale:
Serotonin syndrome can occur if a selective serotonin reuptake inhibitor is combined with a monoamine oxidase inhibitor, a tryptophan-serotonin precursor, or St. John's wort. Signs and symptoms of serotonin syndrome include restlessness or agitation, headache, diaphoresis, ataxia, myoclonus, shivering, tremor, diarrhea, nausea, abdominal cramps, and hyperreflexia. Constipation is not associated with
serotonin syndrome.
D] Edema
Rationale:
Assess for and identify signs and symptoms of lithium toxicity, which include diarrhea, lethargy, slurred speech, muscle weakness, ataxia, seizures, edema, hypotension, and circulatory collapse. Hypertension, energetic behavior, and elevated muscle response are not signs of lithium poisoning.
Cheddar cheese
Pepperoni
Red wine
Foods high in tyramine include aged cheeses [cheddar, blue, swiss], Smoked or pickled meats [herring, sausage, corned beef, smoked fish or poultry, salami, pepperoni], aged or fermented meats, red wines, and Italian broad beans.
•Headache, drowsiness, dizziness, hypotension, dysrhythmias, Restlessness, slurred speech, dry mouth, metallic taste, GI distress, tremors, muscle weakness, edema of hands and ankles, increased urination, blood dyscrasias, nephrotoxicity
1.Teach patient signs of toxicity: persistent nausea, vomiting, severe diarrhea, slurred speech, blurred vision increased thirst, increasing tremors, lack of coordination, confusion, drowsiness, dysrhythmias, seizures, coma
2.Teach patient to wear medical alert identification.
3.Teach patient to take drug as prescribed and
keep medical appointments. Lithium levels will be monitored every month.
4.Warn against driving motor vehicles or operating dangerous equipment until drug effect is known.
5.Advise patient that drug effect may take 1 to 2 weeks.
6.*Encourage patient to avoid caffeine[can cause manic-episodes], crash diets, NSAIDs, diuretics[wastes sodium].
7.*Encourage patient to maintain adequate sodium intake. These patients will be encouraged to eat sodium, instead of avoid
sodium.
8.Encourage adequate fluid intake [2-3 L daily initially, 1.5 to 2 L daily maintenance].
9.Take with food to decrease GI irritation.
persistent nausea, vomiting, severe diarrhea, slurred speech, blurred vision increased thirst, increasing tremors, lack of coordination, confusion, drowsiness, dysrhythmias, seizures, coma
Drowsiness, dizziness, insomnia, headache, euphoria, amnesia, blurred vision, photosensitivity, sexual dysfunction, hypertension, angioedema, blood dyscrasias, suicidal ideation, Stevens-Johnson syndrome
•Sedation, dizziness, headache, peripheral edema, weight gain, anticholinergic effects, seizures, tachycardia, EPS, hypotension/hypertension, NMS
Sets found in the same foldera. Vital signs
All the options should be assessed. Each pertains to biological and safety needs for the client. Nurses must follow hospital protocol for care. Generally, clients should be observed for level of consciousness at 15-minutes intervals, given food at normal meal times or more often if they are hyperactive, given flouids hourly, have vital signs checked at 4 hour intervals or less if medications administration has caused hypotension, taken to the bathroom every 2
hours, and released from restraints and given range of motion every 2 hours.
b. Nutritional needs
All the options should be assessed. Each pertains to biological and safety needs for the client. Nurses must follow hospital protocol for care. Generally, clients should be observed for level of consciousness at 15-minutes intervals, given food at normal meal times or more often if they are hyperactive, given flouids hourly, have vital signs checked at 4 hour intervals or less if medications
administration has caused hypotension, taken to the bathroom every 2 hours, and released from restraints and given range of motion every 2 hours.
c. Level of awareness
All the options should be assessed. Each pertains to biological and safety needs for the client. Nurses must follow hospital protocol for care. Generally, clients should be observed for level of consciousness at 15-minutes intervals, given food at normal meal times or more often if they are hyperactive, given flouids
hourly, have vital signs checked at 4 hour intervals or less if medications administration has caused hypotension, taken to the bathroom every 2 hours, and released from restraints and given range of motion every 2 hours.
d. Hydration
All the options should be assessed. Each pertains to biological and safety needs for the client. Nurses must follow hospital protocol for care. Generally, clients should be observed for level of consciousness at 15-minutes intervals, given food at normal
meal times or more often if they are hyperactive, given flouids hourly, have vital signs checked at 4 hour intervals or less if medications administration has caused hypotension, taken to the bathroom every 2 hours, and released from restraints and given range of motion every 2 hours.
e. Elimination needs
All the options should be assessed. Each pertains to biological and safety needs for the client. Nurses must follow hospital protocol for care. Generally, clients should be observed
for level of consciousness at 15-minutes intervals, given food at normal meal times or more often if they are hyperactive, given flouids hourly, have vital signs checked at 4 hour intervals or less if medications administration has caused hypotension, taken to the bathroom every 2 hours, and released from restraints and given range of motion every 2 hours.
f. Range of Motion and comfort needs
All the options should be assessed. Each pertains to biological and safety needs for the
client. Nurses must follow hospital protocol for care. Generally, clients should be observed for level of consciousness at 15-minutes intervals, given food at normal meal times or more often if they are hyperactive, given flouids hourly, have vital signs checked at 4 hour intervals or less if medications administration has caused hypotension, taken to the bathroom every 2 hours, and released from restraints and given range of motion every 2 hours.