A nurse is caring for a client prescribed Vancomycin. Which nursing action is most appropriate regarding infusing over at least 60 minutes to prevent Red Man Syndrome and monitoring trough levels?
1Instruct the mother to stop fluoxetine now because these signs indicate the medication is worsening depression and causing suicidal ideation.
2Conduct a direct suicide risk assessment now — ask about ideation, plan, means, and prior attempts, and create a safety plan with the family.✓ Correct answer
3Explain that increased energy and quieter mood often occur early with fluoxetine and signal the depression is starting to lift, so no intervention is required.
4Advise the family to wait for the next scheduled outpatient appointment in 4 weeks because these reactions often resolve without intervention.
Explanation
When administering Vancomycin, key nursing considerations include monitoring patient status, checking critical laboratory values, and providing appropriate safety education. Unsafe practices such as stopping medications abruptly or doubling missed doses are incorrect.
Asking directly about suicide does NOT plant the idea — silence does. The standard for adolescents on a new SSRI is weekly follow-up for the first 4 weeks, then biweekly, with explicit family education on warning signs.
Scenario A 16-year-old with newly diagnosed MDD has been on fluoxetine 20 mg PO daily for 1 week. The mother calls the clinic: the teen is "more active" but withdrawn, has organized old photos, given a guitar to a friend, and texted "I love you Mom" last night. No prior suicide attempt is documented but the teen has access to the household firearm. The teen is currently at home with the parent and is willing to come to the clinic.
SSRI black box warning — FDA boxed warning (2004/2007): increased risk of suicidal thinking and behavior in children, adolescents, and young adults <25, particularly in the first 1–2 months and after dose changes. Requires explicit informed consent and weekly monitoring early in therapy.
C-SSRS — Columbia Suicide Severity Rating Scale — a brief, validated tool that screens ideation intensity, behavior, and frequency. Used to triage low/moderate/high risk and guide level-of-care decisions.
Means restriction — Reducing access to lethal methods (firearms locked or removed, limited medication supply, sharps secured) is one of the strongest evidence-based interventions to prevent suicide and is a core element of any safety plan.