Difficulty: Medium
Average Score: 94%
Simulated
Passage / Scenario
History and PhysicalNurse Notes
Vital Signs
A 23-year-old female presents to the emergency department with altered mental status. She is accompanied by her roommate. The roommate says that symptoms started around 0900 today and have progressively worsened. She says the client first appeared euphoric but would switch to being irritable. The client also reported diarrhea and nausea. The client is combative. The client has a history of major depressive disorder and is being treated with paroxetine 50 mg PO once daily.
Which assessment findings require follow-up by the nurse?
Correct answer
A,B,C,D,E,H
Rationale
Myoclonus, fever, hypertension, altered mental status, tachycardia, and diaphoresis suggest serotonin syndrome, requiring immediate follow-up to manage this life-threatening condition.