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A nurse is assessing a client who has major depressive disorder. Which of the following findings should the nurse expect? (Select all that apply)
- A. Anhedonia
- B. Insomnia
- C. Weight gain
- D. Flight of ideas
- E. Feelings of worthlessness
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. Anhedonia is a key feature of major depressive disorder characterized by the inability to feel pleasure. Insomnia commonly occurs due to disrupted sleep patterns. Feelings of worthlessness are typical in depression due to negative self-perception. Weight gain is less common in major depressive disorder, typically weight loss is more prevalent. Flight of ideas is not a typical finding in major depressive disorder, as it is more associated with manic episodes in bipolar disorder.
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A nurse is teaching a client who has generalized anxiety disorder about buspirone. Which statement indicates the client understands the teaching?
- A. I should take this medication as needed for acute anxiety.
- B. I may experience sedation and drowsiness with this medication.
- C. I should avoid grapefruit juice while taking this medication.
- D. This medication has a risk for dependence.
Correct Answer: C
Rationale: The correct answer is C because grapefruit juice can interact with buspirone, leading to an increased risk of side effects. Taking the medication with grapefruit juice can affect its absorption and metabolism, potentially altering its effectiveness. Choice A is incorrect because buspirone is typically taken regularly, not as needed. Choice B is incorrect because buspirone is not known for causing significant sedation or drowsiness. Choice D is incorrect because buspirone is not associated with a risk for dependence.
A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)
- A. Give the client one simple direction at a time.
- B. Refute the client's delusions using logic.
- C. Allow the client to choose among a variety of activities each day.
- D. Reinforce orientation to time, place, and person.
- E. Establish eye contact when communicating with the client.
Correct Answer: A, D, E
Rationale: Correct Answer: A, D, E
Rationale:
A: Giving the client one simple direction at a time is important as individuals with dementia may have difficulty processing complex information.
D: Reinforcing orientation to time, place, and person helps maintain the client's sense of reality and reduce confusion.
E: Establishing eye contact when communicating with the client promotes engagement and helps in maintaining their attention.
Summary:
B: Refuting the client's delusions using logic can be counterproductive as it may cause distress and worsen their symptoms.
C: Allowing the client to choose among a variety of activities may overwhelm them. It is better to provide structured activities.
F & G: Not applicable.
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: Correct Answer: B
Rationale:
- Choice B indicates an understanding of the delayed onset of action of amitriptyline, which typically takes a couple of weeks to produce therapeutic effects.
- This knowledge is crucial for managing client expectations and adherence to treatment.
- Choices A, C, and D are incorrect:
- A: Taking St. John's wort with amitriptyline can result in serotonin syndrome due to potential drug interactions.
- C: Amitriptyline can actually lower blood pressure, not raise it.
- D: Amitriptyline is usually taken with food to minimize gastrointestinal side effects.
- In summary, choice B reflects the correct understanding of the medication's timeline for efficacy, while the other choices demonstrate misconceptions or potential risks.
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.
A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. Which of the following medications should the nurse expect to administer?
- A. Methadone
- B. Disulfiram
- C. Lorazepam
- D. Bupropion
Correct Answer: C
Rationale: The correct answer is C: Lorazepam. Lorazepam is a benzodiazepine used to manage alcohol withdrawal symptoms by reducing anxiety, seizures, and agitation. Methadone (A) is used for opioid addiction, Disulfiram (B) is for alcohol aversion therapy, and Bupropion (D) is for smoking cessation. The other choices are not appropriate for alcohol withdrawal management.