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A client with schizophrenia is prescribed risperidone. Which of the following should the nurse monitor for as an adverse effect of this medication?
- A. Increased blood pressure
- B. Weight gain
- C. Excessive salivation
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Weight gain. Risperidone is an antipsychotic medication known to cause metabolic side effects such as weight gain. This is due to its impact on appetite regulation and metabolism. Monitoring weight is crucial to prevent complications such as diabetes and cardiovascular issues.
A: Increased blood pressure is not a common adverse effect of risperidone.
C: Excessive salivation is not a typical side effect of risperidone.
D: Bradycardia is not associated with risperidone use in clients with schizophrenia.
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A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?
- A. "I can continue to take St. John's wort while taking this medication."
- B. "I know it will be a couple of weeks before the medication helps me feel better."
- C. "I expect this medication to raise my blood pressure."
- D. "I should take this medication on an empty stomach."
Correct Answer: B
Rationale: The correct answer is B: "I know it will be a couple of weeks before the medication helps me feel better." This statement indicates an understanding of the teaching because amitriptyline, a tricyclic antidepressant, typically takes a few weeks to reach its full therapeutic effect in treating depressive symptoms. This indicates the client understands the delayed onset of action of the medication.
Incorrect options:
A: "I can continue to take St. John's wort while taking this medication." - St. John's wort can interact with amitriptyline, leading to potentially dangerous side effects.
C: "I expect this medication to raise my blood pressure." - Amitriptyline can indeed cause orthostatic hypotension, not raise blood pressure.
D: "I should take this medication on an empty stomach." - Amitriptyline is usually taken with food to minimize gastrointestinal side effects.
A nurse is caring for a client with major depressive disorder who has a new prescription for fluoxetine. Which statement by the client indicates an understanding of the medication?
- A. I should expect to see improvement in my mood within a few days.
- B. I may experience increased thoughts of suicide at the beginning of treatment.
- C. I need to avoid foods high in tyramine while taking this medication.
- D. I will need to have my lithium levels checked regularly.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Fluoxetine is an antidepressant that can initially increase suicidal thoughts in some individuals, especially at the beginning of treatment.
2. This phenomenon is known as "activation syndrome" and is important for clients to be aware of.
3. Monitoring for any signs of increased suicidal thoughts is crucial for client safety.
4. Options A, C, and D are incorrect because fluoxetine does not provide immediate mood improvement, does not require avoiding tyramine-rich foods, and does not affect lithium levels.
A nurse is planning care for a client who has borderline personality disorder and engages in self-mutilation. Which intervention should the nurse include?
- A. Restrict the client's access to personal belongings.
- B. Encourage the client to express feelings of anger.
- C. Place the client in seclusion when self-injurious behavior occurs.
- D. Tell the client to stop the self-mutilation behavior.
Correct Answer: B
Rationale: The correct answer is B: Encourage the client to express feelings of anger. For a client with borderline personality disorder and self-mutilation behavior, it is essential to address underlying emotions. Encouraging the client to express feelings of anger can help them identify and process their emotions, reducing the likelihood of resorting to self-injury. Restricting access to personal belongings (A) may lead to feelings of frustration and exacerbate the behavior. Placing the client in seclusion (C) may cause feelings of abandonment and increase distress. Simply telling the client to stop self-mutilation (D) overlooks the complex emotional reasons behind the behavior.
A client with schizophrenia is prescribed risperidone. Which of the following should the nurse monitor for as an adverse effect of this medication?
- A. Increased blood pressure
- B. Weight gain
- C. Excessive salivation
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Weight gain. Risperidone, an atypical antipsychotic, is known to cause metabolic side effects such as weight gain. This occurs due to its effects on increasing appetite and altering metabolism. Monitoring weight regularly is crucial to detect and manage this adverse effect to prevent complications like diabetes and cardiovascular issues. Increased blood pressure (A) is not a common adverse effect of risperidone. Excessive salivation (C) is more commonly associated with medications like clozapine. Bradycardia (D) is not a typical side effect of risperidone.
A nurse is admitting a client who has dementia to a long-term care facility. The client tells the nurse that she lived in this facility years ago and took care of all the residents by herself. The nurse should document this as which of the following findings?
- A. Projection
- B. Perseveration
- C. Agnosia
- D. Confabulation
Correct Answer: D
Rationale: The correct answer is D: Confabulation. Confabulation is the creation of false memories or distortion of actual memories without the intention to deceive. In this scenario, the client is not intentionally lying, but rather recalling a memory that did not occur. This is common in individuals with dementia. Projection (A) involves attributing one's thoughts or feelings to someone else. Perseveration (B) is the persistent repetition of a response. Agnosia (C) is the inability to recognize familiar objects or people. In this case, the client's statement aligns most closely with confabulation, making it the correct choice.