Practice Question
A nurse is reviewing the medical records for a group of clients prior to administering the clients' medications. For which of the following clients should the nurse withhold the prescribed medication and notify the provider?
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Correct Answer:
A client who is taking fluoxetine and exhibits muscle rigidity and tachycardia
Rationale:
💎 Fluoxetine is an SSRI (Selective Serotonin Reuptake Inhibitor), and the combination of muscle rigidity and tachycardia suggests serotonin syndrome, a potentially life-threatening adverse effect.
💎 Serotonin syndrome occurs due to excess serotonin accumulation in the CNS, often characterized by neuromuscular hyperactivity, autonomic instability, and altered mental status.
💎 Immediate action is to withhold the medication and notify the provider—early recognition prevents progression to hyperthermia, seizures, or shock.
💎 Monitoring vital signs, muscle tone, reflexes, and temperature is essential while providing supportive care and discontinuing serotonergic agents.
💎 Mild side effects (e.g., yawning, dry mouth, or mild nausea) are expected with other antidepressants, but rigidity and tachycardia indicate a medical emergency.
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This question is from RN Mental Health 2023 ( Oct 2025) which contains 70 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Mental Health
- Answer Choices: 4