Nokea
A nurse is collecting data from a client who is taking amitriptyline. Which of the following findings should the nurse report to the provider as an adverse effect of the medication?
- A. A systolic blood pressure decrease of 15 mm Hg after standing
- B. Hypersalivation
- C. Tinnitus
- D. A weight loss of 3.6 kg (8 lb) over a 6-month time period
Correct Answer: A
Rationale: A decrease in systolic blood pressure of 15 mm Hg after standing could indicate orthostatic hypotension, which is a known adverse effect of amitriptyline. Orthostatic hypotension can lead to dizziness, lightheadedness, and falls, posing a significant risk to the patient's safety. Reporting this finding to the provider is crucial for assessing the need for dosage adjustments or alternative treatments.
You may also like to solve these questions
A nurse is monitoring a client who is receiving haloperidol. Which of the following findings is the priority to report to the provider?
- A. Hypoactive bowel sounds in all four quadrants.
- B. Client report of dry mouth.
- C. Constant opening and closing of mouth.
- D. Client report of photosensitivity.
Correct Answer: C
Rationale: Constant opening and closing of the mouth, also known as tardive dyskinesia, is a serious side effect of haloperidol and other antipsychotic medications. This condition involves involuntary muscle movements and can be irreversible. It is crucial to report this finding to the provider immediately for assessment and potential adjustment of the medication regimen.
A nurse is working with a group of clients during group therapy. For which of the following client disorders will setting limits serve as an appropriate behavioral management technique?
- A. Delirium
- B. Depression
- C. Antisocial personality disorder
- D. Generalized anxiety disorder
Correct Answer: C
Rationale: Setting limits is an essential behavioral management technique for clients with antisocial personality disorder. Individuals with this disorder often exhibit manipulative, deceitful, and aggressive behaviors. Clear and consistent limits help establish boundaries and prevent the exploitation of others. This approach promotes accountability and helps manage inappropriate behaviors in a therapeutic setting.
A nurse is collecting data from a group of clients in an acute care mental health facility. For which of the following findings should the nurse be most concerned regarding individual client safety?
- A. A client who has borderline personality disorder and acts impulsively
- B. A client who has avoidant personality disorder and becomes anxious in social situations
- C. A client who has dependent personality disorder and clings to nursing staff
- D. A client who has histrionic personality disorder and seeks constant attention
Correct Answer: A
Rationale: Clients with borderline personality disorder (BPD) who act impulsively can be a significant safety concern. Impulsive behaviors in BPD can include self-harm, suicidal ideation, substance abuse, and other risky actions. These behaviors can pose immediate and severe threats to the client's safety and require close monitoring, intervention, and support.
A nurse is reinforcing teaching with a client who has generalized anxiety disorder and a new prescription for buspirone. Which of the following information should the nurse include?
- A. This medication is known to cause dependence.
- B. Avoid consuming large amounts of leafy, green vegetables while taking this medication.
- C. It can take several weeks before you notice an effect from the medication.
- D. If a dose is missed, you can take the missed dose along with the next scheduled dose.
Correct Answer: C
Rationale: Buspirone typically takes several weeks to achieve its full therapeutic effect. Clients should be advised to continue taking the medication as prescribed and not to expect immediate relief of anxiety symptoms. This information helps set realistic expectations and encourages adherence to the treatment plan.
A nurse is discussing the care of a client who has alcohol use disorder with another nurse. Which of the following statements should the nurse identify as an indication of countertransference?
- A. The client is just like my parent, who never could quit drinking.
- B. The client needs to accept responsibility for their drinking.
- C. The client asked me to go on a date.
- D. The client shares their feelings openly during group therapy.
Correct Answer: A
Rationale: This statement is an indication of countertransference because the nurse is projecting personal feelings and experiences onto the client. By comparing the client to their parent who struggled with drinking, the nurse may unconsciously treat the client differently based on unresolved emotions or past experiences. Countertransference can interfere with the nurse's ability to provide objective and compassionate care.