# A 32-year-old client on chronic fluoxetine for major depression presents with new agitation, sweating, tremor, hyperreflexia with clonus, T 39.4°C, HR 130, BP 168/96, after starting sumatriptan and tramadol for migraine plus an OTC dextromethorphan cold remedy. Which is the priority nursing action?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375253&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A 32-year-old client on chronic fluoxetine for major depression presents with new agitation, sweating, tremor, hyperreflexia with clonus, T 39.4°C, HR 130, BP 168/96, after starting sumatriptan and tramadol for migraine plus an OTC dextromethorphan cold remedy. Which is the priority nursing action?

## Option

1. Discontinue the self‑administered dextromethorphan and the as‑needed sumatriptan, but continue the prescribed fluoxetine and tramadol as these are essential for depression and pain management; administer acetaminophen for fever and lorazepam for agitation, and monitor vital signs every 4 hours, with the expectation that symptoms will resolve as the short‑acting agents clear.
2. Administer naloxone 0.4 mg intravenously stat to reverse suspected opioid overdose from tramadol, continue the fluoxetine, sumatriptan, and dextromethorphan as prescribed, apply external cooling for the elevated temperature, transfer the client to a step‑down unit for continuous pulse oximetry and sedation monitoring, and administer acetaminophen 650 mg orally for fever.
3. Recognize neuroleptic malignant syndrome as the likely diagnosis, discontinue fluoxetine immediately, administer dantrolene sodium 2.5 mg/kg intravenously, initiate active cooling measures, provide supportive care in a monitored unit, and continue tramadol, sumatriptan, and dextromethorphan as they are not known to trigger NMS.
4. Recognize serotonin syndrome and act immediately: stop all serotonergic agents (fluoxetine, sumatriptan, tramadol, dextromethorphan), supportive care including IV fluids and cooling, benzodiazepines for agitation, and consider cyproheptadine for moderate to severe cases; transfer to a monitored unit; review home medications including OTC. **✔ Correct answer**

**Correct answer: 4**

## Explanation

Serotonin syndrome arises from excess serotonergic activity, often from drug combinations. Diagnostic features (Hunter criteria): mental status changes (agitation, confusion), neuromuscular hyperactivity (hyperreflexia, clonus including ocular clonus, tremor, rigidity), and autonomic instability (hyperthermia, tachycardia, hypertension, diaphoresis, mydriasis, GI symptoms). Onset typically within hours of the inciting combination. Common offenders: SSRI/SNRI/TCA, MAOIs (including linezolid, methylene blue, recent rasagiline/selegiline), triptans, tramadol, meperidine, dextromethorphan, ondansetron, St John wort, MDMA, fentanyl, lithium. Standard nursing response: (1) recognize and immediately stop all serotonergic agents; (2) support — IV fluids, cooling for hyperthermia (active cooling for >38.5C; intubation/paralysis if severe), benzodiazepines for agitation and to reduce muscle activity; (3) cyproheptadine 12 mg PO/NG initial then 2 mg every 2 hours, max 32 mg/day, for moderate-to-severe symptoms; (4) avoid antipyretics like acetaminophen alone (centrally driven hyperthermia) and physical restraints (worsen muscle activity); (5) ICU transfer if severe; (6) review home OTC and herbals; educate about SSRI washout when planning future serotonergic therapy. Continuing, adding SSRI, naloxone alone are unsafe.

## In-depth explanation

Hyperreflexia with clonus + autonomic instability + serotonergic stack = serotonin syndrome. Stop everything serotonergic, support, benzodiazepines, cyproheptadine for moderate-severe.

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