Patient Data Exhibits Which assessment findings require follow-up by the nurse? Select all that apply.

Choice A: Myoclonus Myoclonus refers to sudden, involuntary muscle jerks. In the context of this patient’s presentation, myoclonus is significant because it can be a symptom of serotonin syndrome, a potentially life-threatening condition that can occur with the use of serotonergic medications like paroxetine. Serotonin syndrome is characterized by a triad of cognitive, autonomic, and somatic effects, including altered mental status, autonomic instability, and neuromuscular abnormalities such as myoclonus. Therefore, the presence of myoclonus in this patient warrants immediate follow-up to rule out serotonin syndrome and initiate appropriate treatment if necessary. Choice B: Temperature 102°F (38.8°C) A temperature of 102°F (38.8°C) is indicative of a fever, which is an abnormal finding that requires follow-up. Fever can be a sign of infection or other inflammatory processes. In the context of this patient’s symptoms, including altered mental status and myoclonus, a high fever could also be a sign of serotonin syndrome. Normal body temperature ranges from 97.8°F to 99.1°F (36.5°C to 37.3°C). A temperature above this range is concerning and requires further investigation to determine the underlying cause and appropriate intervention. Choice C: Blood Pressure 168/94 mm Hg The patient’s blood pressure of 168/94 mm Hg is significantly elevated. Normal blood pressure for adults is typically around 120/80 mm Hg. Hypertension can be a sign of autonomic instability, which is another component of serotonin syndrome. Elevated blood pressure can also increase the risk of cardiovascular events such as stroke or heart attack. Therefore, this finding requires follow-up to manage the patient’s blood pressure and address any underlying causes. Choice D: Altered Mental Status Altered mental status is a broad term that encompasses changes in cognitive function, including confusion, disorientation, and altered levels of consciousness. This patient’s altered mental status, combined with other symptoms such as fever and myoclonus, raises concern for serotonin syndrome. Altered mental status can also be caused by other conditions such as infections, metabolic disturbances, or neurological disorders. Immediate follow-up is necessary to determine the cause and provide appropriate treatment. Choice E: Heart Rate 118 beats/minute A heart rate of 118 beats per minute is considered tachycardia, which is an abnormally fast heart rate. The normal resting heart rate for adults ranges from 60 to 100 beats per minute. Tachycardia can be a sign of autonomic instability, which is seen in conditions like serotonin syndrome. It can also be caused by fever, dehydration, or other underlying conditions. Follow-up is required to assess the cause of the tachycardia and manage it appropriately. Choice F: Respirations 16 breaths/minute A respiratory rate of 16 breaths per minute is within the normal range for adults, which is typically 12 to 20 breaths per minute. Therefore, this finding does not require immediate follow-up. However, it is important to continue monitoring the patient’s respiratory status, especially given the other concerning symptoms. Choice G: Capillary Refill Capillary refill time of less than 3 seconds is considered normal. This indicates that the patient’s peripheral perfusion is adequate. Therefore, this finding does not require follow-up. However, it is important to continue monitoring for any changes in perfusion status. Choice H: Diaphoresis Diaphoresis, or excessive sweating, is another symptom that requires follow-up. It can be a sign of autonomic instability and is commonly seen in serotonin syndrome. Diaphoresis can also be associated with other conditions such as infections, hyperthyroidism, or anxiety. Given the patient’s other symptoms, it is important to investigate the cause of the diaphoresis and address it as part of the overall management plan. Choice I: Lung Sounds Lung sounds are noted to be clear, which is a normal finding. This indicates that there are no immediate respiratory issues such as pneumonia or pulmonary edema. Therefore, this finding does not require follow-up. However, it is important to continue monitoring the patient’s respiratory status, especially given the other concerning symptoms.