medium · NCLEX-RN physiological
At 1645, a client on the medical unit who is receiving sertraline for depression and recently started tramadol for pain develops a temperature of 39.2circC, heart rate of 128/min, and inducible clonus in the lower extremities.
What is the nurse's first action?
- Apply four-point soft restraints to prevent injury from the leg movements, for this client.
- Reassess the client in one hour after providing a quiet environment for anxiety, for this client.
- Administer the ordered dose of acetaminophen for the fever.
- Hold all serotonergic medications and notify the provider of suspected serotonin syndrome.
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