# A 42-year-old client has taken sertraline 150 mg daily for depression for 2 years. Tramadol 50 mg every 6 hours was started 24 hours ago for a fractured wrist. The client reports no alcohol use for more than 1 year and takes no antipsychotic medication. The client is now restless and agitated. Temperature is 38.6 C (101.5 F), heart rate 124/min, and blood pressure 158/96 mm Hg. The skin is diaphoretic, pupils are 6 mm and reactive, and bowel sounds are hyperactive. Deep tendon reflexes are 4+ in the lower extremities with inducible ankle clonus and ocular clonus; muscle tone in the arms is normal. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617405&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A 42-year-old client has taken sertraline 150 mg daily for depression for 2 years. Tramadol 50 mg every 6 hours was started 24 hours ago for a fractured wrist. The client reports no alcohol use for more than 1 year and takes no antipsychotic medication. The client is now restless and agitated. Temperature is 38.6 C (101.5 F), heart rate 124/min, and blood pressure 158/96 mm Hg. The skin is diaphoretic, pupils are 6 mm and reactive, and bowel sounds are hyperactive. Deep tendon reflexes are 4+ in the lower extremities with inducible ankle clonus and ocular clonus; muscle tone in the arms is normal. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Alcohol withdrawal
Neuroleptic malignant syndrome
Anticholinergic toxicity
Serotonin syndrome

Actions to take

Select 2
Hold sertraline and tramadol and notify the provider
Administer prescribed IV dantrolene
Give prescribed acetaminophen for the fever
Administer prescribed IV lorazepam for agitation
Apply soft wrist restraints to prevent self-injury now

Parameters to monitor

Select 2
CIWA-Ar alcohol withdrawal score
Core body temperature
Postvoid residual bladder volume
Serum sodium concentration
Clonus and deep tendon reflexes

## Explanation

Rapid onset after adding tramadol to sertraline, with agitation, diaphoresis, hyperthermia, hyperreflexia, and inducible and ocular clonus, meets the pattern of serotonin syndrome. The nurse holds both serotonergic drugs, notifies the provider, and gives a benzodiazepine for agitation. Temperature and clonus with reflexes show whether toxicity is resolving. Dantrolene, antipyretics, and restraints fit other problems or worsen muscle-generated heat.

## In-depth explanation

Quick answer
Serotonin syndrome; hold sertraline and tramadol with provider notification, give the prescribed IV benzodiazepine, and monitor core body temperature, clonus, and deep tendon reflexes.

Why this is correct
Tramadol has serotonergic activity, and adding it to an SSRI can cause serotonin toxicity within hours. The key discriminators are neuromuscular: hyperreflexia and inducible and ocular clonus, together with diaphoresis and hyperactive bowel sounds. Removing the serotonergic drugs stops the cause, and a benzodiazepine reduces agitation and muscle activity that generate heat.

Easy analogy or mental picture
Picture a volume knob turned up by two hands at once: the nervous system is over-amplified, so the reflexes echo and jerk (clonus) instead of stiffening like a lead pipe.

Memory hook
Clonus and a new serotonergic drug = serotonin; rigid and slow on an antipsychotic = NMS.

NCLEX decision rule
When a new drug is added and toxicity appears within 24 hours, stop the offending agents and support the client; choose parameters that follow the defining signs (temperature and neuromuscular findings).

Why the other choices are wrong
Neuroleptic malignant syndrome develops over days after an antipsychotic and shows lead-pipe rigidity with slowed reflexes, so dantrolene is the wrong fit here. Anticholinergic toxicity produces dry skin, absent bowel sounds, and urinary retention, which is why postvoid residual volume is tempting but does not apply. Alcohol withdrawal is unlikely with no alcohol use for more than a year, so a CIWA-Ar score is not useful. Antipyretics do not lower heat generated by muscle activity, and restraints increase isometric contraction and temperature. Serum sodium is not a marker of this condition.

References
1MedlinePlus: Serotonin syndromeClonus and hyperreflexia after serotonergic exposure are the key diagnostic features.
2MedlinePlus — Serotonin syndromeTreatment includes stopping the serotonergic medications and benzodiazepines for agitation.

## Clinical scenario

Scenario
Within 24 hours of adding tramadol to sertraline, a client develops agitation, hyperthermia, diaphoresis, hyperreflexia, and inducible and ocular clonus.

## Key concepts

- **Inducible clonus** — Rhythmic involuntary muscle contractions triggered by briskly dorsiflexing the foot.
- **Ocular clonus** — Slow, continuous horizontal eye movements seen in serotonin toxicity.
- **Hunter criteria** — Clinical criteria for serotonin toxicity that rely on clonus, hyperreflexia, agitation, and hyperthermia after serotonergic exposure.

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