A client being treated for depression with a selective serotonin reuptake inhibitor (SSRI) becomes agitated and diaphoretic and complains of muscle spasms and tremors
The client's sister confides to the nurse that her sister has been taking Saint John's wort daily for the last 6 months. Which action should be taken by the nurse?
1. Ask the client to give the Saint John's wort tablets to the staff.
2. Discuss the dangers of taking over-the-counter herbal preparations with the client.
3. Withhold any scheduled doses of the SSRI and notify the physician.
4. Have the laboratory draw blood work for a serotonin level.
Answer: 3
1. This does not address the critical nature of the situation.
2. This does not address the critical nature of the situation.
3. The symptoms are suggestive of serotonin syndrome as a result of excess serotonin activity from the Saint John's wort and SSRI. It can be fatal, and needs to be reported immediately.
4. This does not address the critical nature of the situation.
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