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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.
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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 unintentional fabrication of memories or events to fill in gaps in memory due to cognitive impairment. In this scenario, the client with dementia is creating false memories of taking care of all the residents by herself, which is a classic example of confabulation. This behavior is not intentional lying but a result of memory deficits.
Choice A: Projection involves attributing one's own unacceptable feelings or thoughts to others, which is not applicable in this context.
Choice B: Perseveration is the repetition of a particular response, such as repeating a word or phrase, which does not align with the client's false memory.
Choice C: Agnosia refers to the inability to recognize familiar objects or people due to brain damage, which is not evident in the client's statement.
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.
A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which of the following clients should the nurse see first?
- A. A client who has narcissistic personality disorder and is mocking others during group therapy
- B. A client who has obsessive-compulsive disorder and is upset about a change in daily routine
- C. A client who has depressive disorder and requires assistance with ADLs
- D. A client who is taking clozapine to treat schizophrenia and reports a sore throat
Correct Answer: D
Rationale: The correct answer is D. The nurse should see the client taking clozapine first due to the potential side effect of agranulocytosis, which can manifest as a sore throat. This is a serious adverse effect that requires immediate attention to prevent complications. The other clients do not present with urgent or life-threatening issues. A: Narcissistic behavior is disruptive but not a medical emergency. B: Upset about a routine change is distressing but does not pose a physical health risk. C: Assistance with ADLs is important but not immediately life-threatening. Therefore, prioritizing the client on clozapine with a sore throat is crucial to ensure timely intervention and prevent serious complications.
A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state?
- A. "What are the voices telling you?"
- B. "I realize the voices are real to you, but I don't hear anything."
- C. "Have you taken your medication today?"
- D. "How long have you been hearing the voices?"
Correct Answer: A
Rationale: The correct answer is A: "What are the voices telling you?" This response demonstrates active listening, assesses the content of the hallucinations, and helps the nurse understand the client's experience. It allows for further assessment and intervention planning. Choice B dismisses the client's experience, choice C focuses on medication compliance rather than addressing the immediate concern, and choice D addresses the duration of the hallucinations but doesn't address the current situation.
A nurse is caring for a client who has a history of opioid use disorder. Which medication should the nurse anticipate administering to prevent withdrawal symptoms?
- A. Methadone
- B. Disulfiram
- C. Naloxone
- D. Bupropion
Correct Answer: A
Rationale: Rationale: A nurse should anticipate administering Methadone to prevent withdrawal symptoms in a client with opioid use disorder. Methadone is a long-acting opioid agonist that helps manage withdrawal symptoms and cravings, making it an effective treatment option. Disulfiram is used for alcohol dependence, Naloxone is an opioid antagonist used for overdose reversal, and Bupropion is an antidepressant. These medications are not indicated for preventing opioid withdrawal symptoms.