Nokea
A 19-year-old male was prescribed sertraline (Zoloft) 3 weeks ago for depression. He calls the clinic today and tells the nurse that he has been feeling increasingly anxious and wants to stop taking the medication because it is not working. The best response for the nurse is
- A. You can stop taking the Zoloft, but let's make another appointment with your provider so you can try a different medication.'
- B. Increased anxiety is a normal side effect for the first few weeks of taking this medication. It will take several weeks to determine if it is working. Please keep taking it as prescribed.'
- C. Increased anxiety is not a normal side effect of Zoloft. What day this week can you come to the clinic to discuss this with your provider?'
- D. Try taking half the prescribed dose for the next week and see if that helps the feelings of anxiety.'
Correct Answer: B
Rationale: Increased anxiety is a common early side effect of SSRIs like sertraline, which typically subsides after a few weeks. The therapeutic effect takes 4-6 weeks. Continuing the medication and monitoring is appropriate.
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While obtaining information about the client's current medication use, the nurse learns that the client takes ginkgo to improve mental alertness. The nurse should tell the client to:
- A. Report signs of bruising or bleeding to the doctor
- B. Avoid sun exposure while using the herbal
- C. Purchase only those brands with FDA approval
- D. Increase daily intake of vitamin E
Correct Answer: A
Rationale: Ginkgo can increase bleeding risk by affecting platelet function, so clients should report signs of bruising or bleeding to their physician.
The nurse has performed discharge teaching to a client in need of a high-iron diet. The nurse recognizes that teaching has been effective when the client selects which meal plan?
- A. Hamburger, French fries, and orange juice
- B. Sliced veal, spinach salad, and whole-wheat roll
- C. Vegetable lasagna, Caesar salad, and toast
- D. Bacon, lettuce, and tomato sandwich; potato chips; and tea
Correct Answer: B
Rationale: Veal and spinach are high in iron, and whole-wheat roll provides additional nutrients. The other meals lack significant iron sources.
A client scheduled for a cardiac catheterization tells the nurse, 'My mother died during this same procedure 10 years ago. I'm afraid the same thing will happen to me.' Which of the following responses by the nurse is the most appropriate?
- A. It's normal to be scared. You are safe here. Let's discuss the procedure.
- B. I'll ask the cardiologist to come and speak with you about your concerns.
- C. We have the best outcomes of any facility in the area for this procedure.
- D. Don't worry. The procedure has improved a lot in the last 10 years.
Correct Answer: A
Rationale: Acknowledging the client’s fear and discussing the procedure provides reassurance and addresses concerns therapeutically.
A nurse on the orthopedics floor is asked by another nurse to witness her waste 1 mg of morphine. The nurse draws the full 2 mg dose of morphine into the syringe and tells the first nurse, 'This client does not get enough pain relief with 1 mg of morphine, so I just go ahead and give 2 mg to keep him comfortable because the doctor won't change the dose.' Which is the correct action by the first nurse?
- A. tell the other nurse to call the doctor back and request an increase in the dosage
- B. refuse to sign off on the waste and report the incident to the charge nurse or unit manager
- C. sign off the waste, and suggest that the nurse give it over two separate doses 30 minutes apart
- D. sign off the waste, but tell the nurse to give it slowly to be sure that the client can tolerate the dose
Correct Answer: B
Rationale: Administering an unordered dose is a medication error and potential diversion. Refusing to sign and reporting ensures patient safety and accountability.
A client diagnosed with lung cancer asks the nurse what the term MO refers to. The nurse says that MO means
- A. no distant metastasis present.
- B. distant metastasis present.
- C. distant metastasis cannot be evaluated.
- D. metastasis present only in immediate lymph nodes.
Correct Answer: A
Rationale: In cancer staging, M0 indicates no distant metastasis, per TNM classification.