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A nurse is caring for a client who has major depressive disorder and is prescribed sertraline. Which of the following instructions should the nurse provide?
- A. Take the medication at bedtime
- B. Expect results within 1 to 2 days
- C. Avoid consuming grapefruit juice
- D. Stop taking the medication once symptoms improve
Correct Answer: C
Rationale: The correct answer is C: Avoid consuming grapefruit juice. Grapefruit juice can interact with sertraline, leading to increased levels of the medication in the bloodstream, potentially causing side effects or toxicity. It is essential for the nurse to instruct the client to avoid grapefruit juice to ensure the safe and effective use of sertraline. Taking the medication at bedtime (choice A) is not specifically necessary for sertraline. Expecting results within 1 to 2 days (choice B) is incorrect as antidepressants like sertraline typically take weeks to show full effects. Stopping the medication once symptoms improve (choice D) can be dangerous as abruptly discontinuing an antidepressant can lead to withdrawal symptoms or a relapse of depression.
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A nurse is caring for a client who has obsessive-compulsive disorder and engages in repeated handwashing. Which of the following actions should the nurse take?
- A. Encourage the client to stop washing hands
- B. Allow the client additional time to complete rituals
- C. Set strict time limits on compulsions
- D. Ignore the client’s compulsive behavior
Correct Answer: B
Rationale: The correct answer is B: Allow the client additional time to complete rituals. This approach is known as a harm reduction strategy in managing obsessive-compulsive disorder. By allowing the client additional time to complete rituals, the nurse can help reduce the client's anxiety and provide a sense of control. Encouraging the client to stop washing hands (A) may increase anxiety and worsen symptoms. Setting strict time limits on compulsions (C) can also increase anxiety and lead to distress. Ignoring the client's compulsive behavior (D) can be harmful as it may reinforce the behavior. It is important for the nurse to be supportive and understanding of the client's struggles while working towards more effective coping strategies.
A nurse is preparing to administer chlorpromazine hydrochloride 25 mg PO to an older adult client. Available is chlorpromazine hydrochloride syrup 10 mg/5 mL. How many mL should the nurse administer?
- A. 12.5
- B. 10
- C. 15
- D. 5
Correct Answer: A
Rationale: The correct answer is A: 12.5 mL. To calculate this, we first determine the total amount needed, which is 25 mg. Then, we use the concentration of the syrup, which is 10 mg/5 mL. By setting up a proportion (25 mg = x mL), we can cross multiply to find x, which equals 12.5 mL. Choice B (10 mL) is incorrect because it does not provide the full 25 mg dose. Choices C (15 mL) and D (5 mL) are incorrect as they do not align with the calculated dose based on the concentration of the syrup.
A nurse is planning care for a client who has bipolar disorder. The client reports not sleeping for 3 days and is exhibiting a euphoric mood. The nurse should identify which of the following as the priority intervention.
- A. Secure the client’s valuable possessions
- B. Limit loud noises in the client’s environment
- C. Encourage the client to participate in structured solitary activities
- D. Provide high calorie snacks to the client
Correct Answer: D
Rationale: The correct answer is D: Provide high calorie snacks to the client. The priority intervention in this scenario is to address the client's lack of sleep and increased energy levels due to mania. Providing high-calorie snacks can help stabilize blood sugar levels and provide sustained energy, potentially aiding in promoting sleep. The other choices are incorrect because securing valuable possessions, limiting loud noises, and encouraging solitary activities do not directly address the immediate need to manage the client's symptoms related to lack of sleep and euphoria.
A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include?
- A. Encourage group activities
- B. Provide frequent rest periods
- C. Offer high-calorie snacks
- D. Allow unlimited physical activity
Correct Answer: B
Rationale: The correct answer is B: Provide frequent rest periods. During manic episodes in bipolar disorder, individuals have high energy levels, reduced need for sleep, and increased activity levels. Providing frequent rest periods helps prevent exhaustion and promotes relaxation, which can help stabilize mood. Encouraging group activities (A) may exacerbate manic symptoms due to increased stimulation. Offering high-calorie snacks (C) can lead to poor dietary choices and worsen physical health. Allowing unlimited physical activity (D) can be dangerous as individuals in a manic state may engage in risky behaviors.
A nurse is caring for a client who has posttraumatic stress disorder related to military service. Which of the following actions should the nurse take?
- A. Encourage the client to suppress feelings of trauma
- B. Assign the same staff to care for the client each day
- C. Address the client in an authoritative manner
- D. Limit the amount of time spent with the client
Correct Answer: B
Rationale: The correct answer is B: Assign the same staff to care for the client each day. Consistency in care providers helps establish trust and a sense of safety for clients with PTSD. This familiarity can reduce anxiety and improve therapeutic rapport. Encouraging the client to suppress feelings of trauma (A) can be harmful as it may worsen symptoms. Addressing the client in an authoritative manner (C) can trigger feelings of threat. Limiting time spent with the client (D) can hinder the development of a therapeutic relationship.