A client being treated with paroxetine (Paxil) 50 mg po daily for depression reports to the clinic
nurse that he took a few extra tablets earlier in the day and "feels bad" now.
The nurse should assess
(more than one answer may be correct)
A. vital signs.
B. for increased suicidal ideation.
C. for presence of abdominal pain and diarrhea.
D. for hyperactivity or feelings of restlessness.
A, C, D
Rationale: The client is taking the maximum dose of this SSRI and has ingested an additional
unknown amount of the drug. Central serotonin syndrome must be considered. Symptoms include
abdominal pain, diarrhea, tachycardia, elevated blood pressure, hyperpyrexia, increased motor
activity, and muscle spasms. Central serotonin syndrome may progress to a full medical emergency
if not treated early. Option B: Although assessing for suicidal ideation is never inappropriate, in this
situation physiological symptoms should be the initial focus.
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