A 12-year-old patient is hospitalized with severe depression. The patient has been taking a selective serotonin reuptake inhibitor (SSRI). What is the priority nursing action for the patient?
A) Monitor food intake for levels of tyramine.
B) Assess for weight loss and difficulty sleeping.
C) Monitor the patient for severe headaches.
D) Implement suicide precautions.
D
Feedback:
Recent studies have linked the incidence of suicide attempts to the use of SSRIs in pediatric patients (see box 21.3 Focus on the Evidence). The priority concern for the nurse would be safety for the patient. Severe headache and reactions to tyramine-containing foods are associated with monoamine oxidase therapy. Weight loss and difficulty sleeping are of a lower priority concern than the patient's safety.
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