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A patient with major depressive disorder is started on fluoxetine. What is a common side effect the nurse should monitor for?
- A. Weight gain
- B. Increased appetite
- C. Nausea
- D. Dry mouth
Correct Answer: C
Rationale: The correct answer is C: Nausea. Fluoxetine, an SSRI antidepressant, commonly causes gastrointestinal side effects such as nausea. This is due to its effect on serotonin levels in the gut. Weight gain (A) and increased appetite (B) are less common side effects of fluoxetine. Dry mouth (D) is more commonly associated with tricyclic antidepressants, not SSRIs. Monitoring for nausea is crucial to ensure patient compliance and well-being.
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A patient with obsessive-compulsive disorder (OCD) spends hours washing their hands. Which nursing intervention is most appropriate?
- A. Encouraging the patient to stop washing their hands
- B. Allowing the patient to wash hands at specified times
- C. Ignoring the patient's behavior
- D. Setting strict limits on the time allowed for hand washing
Correct Answer: B
Rationale: The correct answer is B: Allowing the patient to wash hands at specified times. This option acknowledges the patient's need for hand washing while also setting boundaries. By allowing the patient to wash hands at specified times, the nurse can help establish a routine and gradually reduce the excessive hand washing behavior. Encouraging the patient to stop washing hands (A) may increase anxiety and resistance. Ignoring the behavior (C) can reinforce it. Setting strict limits (D) may cause distress and worsen the OCD symptoms. Option B strikes a balance between addressing the patient's needs and promoting healthier behaviors.
A patient with posttraumatic stress disorder (PTSD) is experiencing flashbacks. What is the best initial intervention?
- A. Encouraging the patient to avoid triggers
- B. Encouraging the patient to talk about their feelings
- C. Providing the patient with relaxation techniques
- D. Advising the patient to avoid social situations
Correct Answer: C
Rationale: The correct initial intervention for a patient with PTSD experiencing flashbacks is providing relaxation techniques (Choice C). This is because relaxation techniques can help the patient cope with the distressing symptoms and manage their anxiety levels during flashbacks. Encouraging the patient to avoid triggers (Choice A) may provide temporary relief but does not address the root cause of the flashbacks. Encouraging the patient to talk about their feelings (Choice B) may be beneficial in the long run but may not be the best initial intervention during a flashback. Advising the patient to avoid social situations (Choice D) can lead to isolation and may not address the immediate distress caused by the flashbacks.
A patient with anorexia nervosa is being treated in an inpatient facility. Which intervention should be included in the care plan?
- A. Allowing the patient to eat alone to reduce stress
- B. Monitoring the patient's weight weekly
- C. Encouraging the patient to exercise daily
- D. Providing the patient with a high-calorie diet
Correct Answer: B
Rationale: The correct answer is B: Monitoring the patient's weight weekly. This intervention is essential in the care plan for a patient with anorexia nervosa as it helps track their progress, assess nutritional status, and identify any concerning weight fluctuations. Regular weight monitoring allows healthcare providers to make timely adjustments to the treatment plan.
Explanation of why the other choices are incorrect:
A: Allowing the patient to eat alone to reduce stress - This choice is incorrect as isolation during meals can exacerbate the patient's eating disorder behaviors and hinder their recovery.
C: Encouraging the patient to exercise daily - Exercise may not be appropriate for a patient with anorexia nervosa due to the risk of excessive physical activity exacerbating their condition.
D: Providing the patient with a high-calorie diet - While increasing calorie intake may be necessary for weight restoration, it should be done under close supervision by healthcare providers and tailored to the individual's needs, making this choice incorrect.
A patient with generalized anxiety disorder (GAD) is prescribed sertraline. What is a common side effect the nurse should monitor for?
- A. Dry mouth
- B. Weight gain
- C. Insomnia
- D. Nausea
Correct Answer: D
Rationale: The correct answer is D: Nausea. Sertraline, a selective serotonin reuptake inhibitor (SSRI), commonly causes gastrointestinal side effects like nausea. This occurs due to increased serotonin levels affecting the digestive system. Dry mouth (A) is more common with other medications like anticholinergics. Weight gain (B) is a potential side effect of some antidepressants but not typically with sertraline. Insomnia (C) can occur with SSRIs, but it is less common than nausea as an initial side effect. Monitoring for nausea is essential to ensure the patient's adherence to treatment and well-being.
While being treated in an inpatient facility, what is the most appropriate intervention for a patient with anorexia nervosa?
- A. Allowing the patient to eat alone to reduce stress
- B. Monitoring the patient's weight daily
- C. Encouraging the patient to exercise daily
- D. Providing the patient with a high-calorie diet
Correct Answer: B
Rationale: The correct answer is B: Monitoring the patient's weight daily. This intervention is crucial in managing anorexia nervosa as it helps track the patient's progress and identify any concerning weight fluctuations promptly. Daily weight monitoring allows healthcare providers to adjust treatment plans accordingly and ensure the patient's safety.
Choice A: Allowing the patient to eat alone to reduce stress is incorrect because isolation during meals can exacerbate the patient's disordered eating behaviors and hinder the recovery process.
Choice C: Encouraging the patient to exercise daily is incorrect as excessive exercise is a common symptom of anorexia nervosa and can further contribute to the patient's physical and psychological health risks.
Choice D: Providing the patient with a high-calorie diet is incorrect without proper monitoring as it can lead to refeeding syndrome and other complications. Monitoring the patient's weight is essential before implementing dietary changes.