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A nurse is caring for a client who has major depressive disorder and was prescribed citalopram 2 weeks ago with a planned dosage increase 1 week ago. The client reports having an improved appetite but still feels very depressed and is still having trouble sleeping. Which of the following actions should the nurse take?
- A. Speak to the provider about adding an MAOI to the current medication regimen.
- B. Explain that antidepressants often take several weeks to be fully effective.
- C. Tell the client that the provider will need to change citalopram to a different medication.
- D. Recommend a sleep study be done on the client.
Correct Answer: B
Rationale: The correct answer is B: Explain that antidepressants often take several weeks to be fully effective. Citalopram, an SSRI, typically takes 2-4 weeks to show significant improvement in depressive symptoms. It is important for the nurse to educate the client about this delayed onset of action to manage expectations and encourage adherence to the medication regimen. Adding an MAOI (A) is not indicated and can lead to dangerous interactions. Changing the medication (C) prematurely may not be necessary before allowing sufficient time for citalopram to work. A sleep study (D) is not warranted at this stage as the primary issue is depression, not solely related to sleep disturbances.
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A nurse in the emergency department is creating a plan of care for a client experiencing alcohol intoxication. Which of the following interventions should the nurse plan to include? (Select all that apply.)
- A. Contact the laboratory to obtain a blood sample.
- B. Prepare the client for a CT scan.
- C. Check the client’s pupil reactivity.
- D. Obtain a urine specimen.
- E. Perform a developmental screening test.
Correct Answer: A, B, C, D
Rationale: The correct interventions for a client experiencing alcohol intoxication are A, B, C, and D. A blood sample is crucial to assess alcohol levels. A CT scan may be needed to rule out head trauma or other underlying issues. Checking pupil reactivity can indicate neurological status. Obtaining a urine specimen helps assess kidney function and possible drug use. Choice E, performing a developmental screening test, is not relevant to the immediate care needs of an individual with alcohol intoxication.
A nurse in a mental health clinic is conducting a staff education session on schizophrenia. Which of the following manifestations should the nurse identify as negative symptoms? (Select all that apply.)
- A. Delusions
- B. Hallucinations
- C. Anhedonia
- D. Poor judgment
- E. Blunt affect
Correct Answer: C, E
Rationale: The correct manifestations for negative symptoms of schizophrenia are C: Anhedonia and E: Blunt affect. Anhedonia refers to the inability to feel pleasure, which is a common negative symptom. Blunt affect is a reduction in the range and intensity of emotional expression, another classic negative symptom. Delusions (A) and hallucinations (B) are positive symptoms involving distorted perceptions and beliefs. Poor judgment (D) is a cognitive symptom, not specific to schizophrenia. The absence of options F and G means they are not applicable to this question.
A nurse is caring for a client who was admitted with delirium tremens five days ago. The client seeks permission from the nurse before performing activities of daily living. This behavior indicates which of the following findings?
- A. The client is ready for discharge.
- B. The client is able to function independently.
- C. The client may be having a recurrence of delirium tremens.
- D. The client is exhibiting dependency.
Correct Answer: D
Rationale: The correct answer is D: The client is exhibiting dependency. This behavior indicates that the client is relying on the nurse for permission before performing activities of daily living, suggesting a level of dependency. This is common in clients with delirium tremens as they may have cognitive impairment and need guidance for decision-making.
A: The client seeking permission does not necessarily indicate readiness for discharge.
B: The client seeking permission does not necessarily indicate ability to function independently.
C: There is no indication of a recurrence of delirium tremens based on seeking permission.
Summary: The correct answer, D, is supported by the client's behavior of seeking permission, indicating dependency. Other choices are incorrect as they do not align with the behavior exhibited by the client in this scenario.
A nurse in a mental health facility is interacting with a client who is angry and becoming increasingly aggressive. Which of the following actions should the nurse take?
- A. Move the client to a private area so the conversation will not be disturbed.
- B. Use clarification to determine what the client is feeling.
- C. Speak to the client using an authoritative voice.
- D. Maintain constant eye contact with the client.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Moving the client to a private area ensures privacy, reduces stimulation, and promotes a sense of safety, which can help de-escalate the situation. It also prevents the client from feeling embarrassed or judged by others, allowing for more open communication. This approach prioritizes the client's emotional well-being and safety.
Summary:
B: While clarification is important for understanding the client's emotions, it may not be the most immediate action needed in a potentially escalating situation.
C: Speaking authoritatively may further agitate the client and escalate the situation.
D: Maintaining constant eye contact could be perceived as confrontational and may escalate aggression.
A nurse is caring for a client who has schizophrenia and tells the nurse, "They lie about me all the time, and they are trying to poison my food." Which of the following statements should the nurse make?
- A. "You are mistaken. Nobody is lying about you or trying to poison you."
- B. "You seem to be having very frightening thoughts."
- C. "Why do you think you are being lied about and poisoned?"
- D. "Who is lying about you and trying to poison you?"
Correct Answer: B
Rationale: The correct answer is B: "You seem to be having very frightening thoughts." This response acknowledges the client's feelings without denying or confirming the delusions. It shows empathy and validates the client's experience without reinforcing the delusions. Option A is incorrect as it denies the client's beliefs, which can lead to distrust. Option C may encourage the client to provide more details about the delusions. Option D may inadvertently validate the delusions by asking for specific details.