# A 78-year-old client with major depressive disorder is started on sertraline 50 mg daily. The nurse reviews the following trend data. Which response is most appropriate at each time point?

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> subject: Medication Administration  
> category: PPT

## Question

A 78-year-old client with major depressive disorder is started on sertraline 50 mg daily. The nurse reviews the following trend data. Which response is most appropriate at each time point?

| Time | Data |
| --- | --- |
| Baseline | data: Sodium 138 mEq/L (135-145), BP 128/76, HR 72, weight 68 kg, no edema, alert and oriented x3, steady gait, urine output 1.5 L/day, fluid intake 1.8 L/day |
| Day 7 | data: Sodium 133 mEq/L (135-145), BP 122/70, HR 78, weight 67.5 kg, no edema, alert and oriented x3, mild unsteadiness when turning, urine output 1.4 L/day, fluid intake 2.0 L/day |
| Day 14 | data: Sodium 128 mEq/L (135-145), BP 108/64 with orthostatic drop to 88/52, HR 92, weight 66.8 kg, no edema, new confusion and lethargy, gait instability requiring assistance, urine output 1.2 L/day, fluid intake 2.2 L/day |
| Day 21 | data: Sodium 123 mEq/L (135-145), BP 100/60 with orthostatic drop to 80/48, HR 102, weight 66.2 kg, no edema, worsening confusion, unable to stand without support, urine output 0.9 L/day, fluid intake 2.0 L/day despite fluid restriction |

Q1. At Day 7, which action is most appropriate?

Initiate hypertonic saline infusion for rapid correction
Discontinue sertraline and start fluid restriction
Notify the provider immediately and hold sertraline
Encourage increased sodium intake and monitor for worsening symptoms

Q2. At Day 14, which finding is the strongest indicator that the client's condition is worsening?

Urine output of 1.2 L/day
Sodium level of 128 mEq/L
Orthostatic hypotension with confusion
Weight loss of 1.2 kg since baseline

Q3. At Day 21, which intervention is the priority?

Continue fluid restriction and recheck sodium in 1 week
Notify the provider and prepare for possible sertraline discontinuation
Administer a bolus of 0.9% sodium chloride
Increase fluid intake to improve urine output

## Explanation

This trend presents a gradual decline in serum sodium with evolving neurologic and hemodynamic changes. The nurse must differentiate expected SSRI effects from early hyponatremia, recognize when conservative measures are sufficient, and identify the point at which urgent provider notification and safety interventions are required.

## In-depth explanation

Quick answer
At 14 days, the sodium of 128 mEq/L with new confusion and orthostatic hypotension indicates clinically significant hyponatremia requiring provider notification and fall precautions. At 7 days, sodium 133 mEq/L with mild unsteadiness warrants increased sodium intake and monitoring, not immediate discontinuation. At 21 days, the worsening sodium despite fluid restriction requires escalation, not continued observation.

Why this is correct
The trend shows a progressive fall in sodium from 138 to 123 mEq/L over 21 days. At day 7, the sodium is mildly low but the client is asymptomatic except for mild unsteadiness; conservative management is appropriate. By day 14, the sodium has dropped to 128 mEq/L with new confusion and orthostatic hypotension, signaling the need for provider notification and safety measures. At day 21, sodium is 123 mEq/L with worsening gait instability and confusion despite fluid restriction, requiring urgent reassessment and likely medication adjustment.

Clinical picture
SSRI-associated hyponatremia typically develops within the first 2-4 weeks of treatment. Early symptoms include nausea, malaise, and unsteady gait. As sodium falls below 130 mEq/L, confusion, lethargy, and orthostatic hypotension may appear. Severe hyponatremia (<125 mEq/L) can lead to seizures, coma, and death. Management includes discontinuing the offending agent, fluid restriction, and slow sodium correction to avoid osmotic demyelination.

Memory hook
Remember the mnemonic 'SALT LOSS' for hyponatremia symptoms: Seizures, Altered mental status, Lethargy, Tachycardia, Low urine output, Orthostatic hypotension, Shallow respirations, Stupor.

NCLEX decision rule
For symptomatic hyponatremia with sodium <130 mEq/L, notify the provider and implement fall precautions. Do not rapidly correct sodium; aim for <10-12 mEq/L in 24 hours. Fluid restriction is first-line for euvolemic hyponatremia, but if sodium continues to fall, the SSRI may need to be discontinued.

Why the alternatives are wrong
At day 7, 'notify provider immediately' is premature because sodium is only mildly low and the client is stable. At day 14, 'encourage increased fluid intake' would worsen dilutional hyponatremia. At day 21, 'continue current plan and recheck in 1 week' is unsafe given the progressive decline and symptoms.

Sources
1NCSBN 2026 NCLEX-RN Test Plan
2DailyMed Sertraline Hydrochloride

## Clinical scenario

The client lives alone, has a history of hypertension and osteoarthritis, and reports decreased appetite since starting sertraline. Baseline weight is 68 kg. The nurse is monitoring for SSRI-associated hyponatremia and related complications.

## Key concepts

- **SIADH** — Syndrome of inappropriate antidiuretic hormone secretion, characterized by euvolemic hyponatremia, low serum osmolality, and inappropriately concentrated urine.
- **Orthostatic hypotension** — A drop in systolic blood pressure of at least 20 mmHg or diastolic of at least 10 mmHg within 3 minutes of standing, often causing dizziness or syncope.
- **Osmotic demyelination syndrome** — A rare but serious neurologic complication caused by overly rapid correction of hyponatremia, leading to dysarthria, dysphagia, quadriparesis, and coma.

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