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A female client with major depression is prescribed fluoxetine (Prozac). She reports experiencing increased energy but still feels sad and hopeless. What is the nurse's best response?
- A. ''These feelings are normal and will pass with time.''
- B. ''Increased energy can sometimes lead to increased risk for self-harm.''
- C. ''The medication needs more time to be effective.''
- D. ''Let's talk about the things that make you feel this way.''
Correct Answer: B
Rationale: The correct answer is B. Increased energy without improvement in mood can increase the risk of self-harm in clients with depression. It is crucial for the nurse to recognize this potential risk and closely monitor the client for any signs of self-harm. Choice A is incorrect because dismissing the client's persistent feelings of sadness and hopelessness as normal may invalidate her experiences. Choice C is incorrect as fluoxetine (Prozac) typically starts showing effectiveness within a few weeks, so further delay is concerning. Choice D is incorrect because while discussing the client's feelings is important, the immediate focus should be on addressing the potential risk of self-harm associated with increased energy.
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The parents of a 14-year-old boy bring their son to the hospital. He is lethargic but responsive. The mother states, 'I think he took some of my pain pills.' During the initial assessment of the teenager, what information is most important for the nurse to obtain from the parents?
- A. If he has seemed depressed recently.
- B. If a drug overdose has ever occurred before.
- C. If he might have taken any other drugs.
- D. If he has a desire to quit taking drugs.
Correct Answer: C
Rationale: In a situation where a teenager is brought to the hospital after possibly ingesting pills, the most crucial information for the nurse to obtain from the parents is whether the teenager might have taken any other drugs (C). This knowledge is vital for guiding further treatment, such as administering antagonists, making it the top priority. While information about depression (A) and previous drug overdoses (B) is valuable for treatment planning, it is not as critical as knowing all substances taken. Asking about the teenager's desire to quit taking drugs (D) is not appropriate during the acute management of a drug overdose and does not take precedence over determining what other substances might have been ingested.
A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature, 100 F, pulse 100, and BP 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis?
- A. Risk for injury related to suicidal ideation.
- B. Risk for injury related to alcohol detoxification.
- C. Knowledge deficit related to ineffective coping.
- D. Health-seeking behaviors related to personal crisis.
Correct Answer: B
Rationale: The most important nursing diagnosis is related to alcohol detoxification (B) because the client has elevated vital signs, a sign of alcohol detoxification. Giving lorazepam (Ativan) to address the elevated vital signs due to alcohol withdrawal is a priority. Addressing the risk for injury related to suicidal ideation (A) should come after stabilizing the client's physiological state. Both (C) and (D) can be addressed once immediate safety needs are met, but the priority is managing the alcohol detoxification to prevent potential complications.
A young adult male client, diagnosed with paranoid schizophrenia, believes that the world is trying to poison him. What intervention should the nurse include in this client's plan of care?
- A. Remind the client that his suspicions are not true.
- B. Ask one nurse to spend time with the client daily.
- C. Encourage the client to participate in group activities.
- D. Assign the client to a room closest to the activity room.
Correct Answer: B
Rationale: A client with paranoid schizophrenia has difficulty with trust and developing a trusting relationship with one nurse (B) is likely to be therapeutic for this client. Choice (A) is argumentative and may increase the client's resistance. Choice (C) might be too overwhelming and anxiety-provoking for the client. Choice (D) could increase the client's stress and anxiety, which are counterproductive in managing paranoid ideations.
When a client with major depressive disorder expresses feelings of worthlessness and hopelessness, what is the nurse's priority intervention?
- A. Encourage the client to engage in recreational activities.
- B. Suggest the client keep a journal of their thoughts and feelings.
- C. Assess the client for suicidal ideation.
- D. Provide the client with positive affirmations.
Correct Answer: C
Rationale: The correct answer is to assess the client for suicidal ideation. When a client expresses feelings of worthlessness and hopelessness, it is crucial to evaluate the risk of self-harm. Encouraging recreational activities (choice A) or suggesting journaling (choice B) may be helpful interventions but assessing for suicidal ideation takes precedence due to the immediate risk of harm. Providing positive affirmations (choice D) is not the priority when safety is a concern.
The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore in depth with the client based on this screening tool?
- A. Cancer screening results, anger, gastritis, daily alcohol intake.
- B. Efforts to cut down, annoyance with questions, guilt, drinking as an 'Eye-opener.'
- C. Consumption, liver enzyme, gastrointestinal complaints and bleeding.
- D. Minimizes drinking, frequently misses family events, guilt about drinking, amount of daily intake.
Correct Answer: B
Rationale: The CAGE questionnaire is used to identify problematic drinking behaviors. Choice B is correct because it includes key aspects that the nurse should explore further with the client. 'Efforts to cut down' can indicate acknowledgment of excessive drinking, 'guilt' reflects emotional distress related to drinking, and 'drinking as an 'Eye-opener'' suggests potential dependency. Choices A, C, and D are incorrect as they do not directly address the essential elements assessed by the CAGE questionnaire and may not provide relevant information for further evaluation of the client's drinking habits.