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A client with a diagnosis of depression is prescribed an SSRI. What is the most important information the nurse should provide?
- A. Take the medication as prescribed.
- B. Avoid consuming grapefruit juice.
- C. Report any thoughts of self-harm immediately.
- D. Understand that improvement may take weeks.
Correct Answer: C
Rationale: The most important information the nurse should provide to a client prescribed an SSRI for depression is to report any thoughts of self-harm immediately. SSRIs can increase suicidal ideation, especially at the beginning of treatment, so it is crucial to monitor for this and take appropriate actions. While it is important to take the medication as prescribed (Choice A), the immediate need for reporting self-harm ideation takes precedence. Avoiding grapefruit juice (Choice B) is a general precaution with certain medications but not as critical in this scenario. Understanding that improvement may take weeks (Choice D) is important for managing treatment expectations, but ensuring the client's safety in the context of suicidal ideation is the top priority.
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The nurse is caring for a client with a diagnosis of bipolar disorder who is taking lithium. What is the most important information the nurse should provide?
- A. Take the medication on an empty stomach.
- B. Monitor sodium intake.
- C. Report any signs of weight gain.
- D. Avoid excessive caffeine intake.
Correct Answer: B
Rationale: The correct answer is B: 'Monitor sodium intake.' Sodium levels can affect lithium levels in the body, so it is crucial to maintain a consistent sodium intake to prevent toxicity or subtherapeutic levels. Option A is incorrect because lithium is usually recommended to be taken on an empty stomach to enhance absorption. Option C, reporting signs of weight gain, is relevant but not as critical as monitoring sodium intake. Option D, avoiding excessive caffeine intake, is important for some individuals but not as essential as monitoring sodium levels when taking lithium.
The nurse is caring for a client who has just undergone a total hip replacement. Which intervention is most important to prevent postoperative complications?
- A. Encourage early ambulation
- B. Apply ice to the surgical site
- C. Monitor the surgical site for signs of infection
- D. Administer pain medication as prescribed
Correct Answer: A
Rationale: Encouraging early ambulation is crucial following a total hip replacement surgery as it helps prevent complications such as deep vein thrombosis (DVT) by promoting circulation. Early ambulation also aids in preventing pneumonia, muscle atrophy, and pressure ulcers. Applying ice to the surgical site may help with pain and swelling, but it is not as critical in preventing complications as early ambulation. While monitoring the surgical site for signs of infection is important, it is not as crucial in preventing postoperative complications compared to early ambulation. Administering pain medication as prescribed is essential for comfort and pain management but does not directly prevent postoperative complications like early ambulation does.
A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing interventions should the nurse include in the plan of care? (Select all that apply.)
- A. Send wound drainage for culture and sensitivity.
- B. Institute contact precautions for staff and visitors.
- C. Use standard precautions and wear a mask.
- D. Monitor the client's white blood cell count.
Correct Answer: B
Rationale: When dealing with a client suspected of having MRSA, the nurse should implement contact precautions to prevent the spread of infection. This includes using gowns and gloves, along with following proper hand hygiene practices. Sending wound drainage for culture and sensitivity may be necessary for diagnostic purposes, but it is not directly related to preventing the spread of infection in this case. Using standard precautions and wearing a mask are not sufficient when dealing with MRSA; contact precautions are specifically required to prevent transmission. Monitoring the client's white blood cell count is important in assessing infection status but is not a primary intervention to prevent the spread of MRSA.
A client is admitted to the hospital with second and third degree burns to the face and neck. How should the nurse best position the client to maximize function of the neck and face and prevent contracture?
- A. The neck extended backward using a rolled towel behind the neck
- B. Prone position using pillows to support both arms outward from the torso
- C. Side-lying position using pillows to support the abdomen and back
- D. The neck forward using pillows under the head and sandbags on both sides
Correct Answer: D
Rationale: After sustaining burns to the face and neck, positioning is crucial to maintain functional posture, reduce pain, and prevent contractures. Placing the neck forward using pillows under the head and sandbags on both sides is the best option in this scenario. This position helps prevent neck and facial contractures, allowing for optimal function and healing. Choices A, B, and C do not adequately address the specific needs of a client with burns to the face and neck. Choice A could potentially exacerbate neck contractures, Choice B focuses on arm support rather than neck and face positioning, and Choice C does not directly address the needs of the burned face and neck, making them less effective in preventing contractures in these critical areas.
A client who has just been diagnosed with tuberculosis (TB) is being discharged home. Which instruction is most important for the nurse to provide?
- A. Avoid close contact with others until treatment is complete
- B. Take all prescribed medications as directed
- C. Schedule a follow-up appointment with the healthcare provider
- D. Wear a mask when in public places
Correct Answer: B
Rationale: The correct answer is B: 'Take all prescribed medications as directed.' This instruction is the most important because adherence to the prescribed medication regimen is crucial in treating tuberculosis effectively and preventing the development of drug-resistant TB. While choice A is important for infection control, ensuring treatment adherence through proper medication intake takes precedence. Choice C is also essential for monitoring progress but is not as critical as ensuring medication compliance. Choice D is relevant for preventing transmission but is not as crucial as ensuring proper treatment by taking medications as directed.