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When assessing a client diagnosed with major depressive disorder who states, 'I feel like I can't go on,' which of the following actions should the nurse take first?
- A. Administer a prescribed antidepressant medication.
- B. Ask the client if they have a plan to commit suicide.
- C. Encourage the client to attend a support group.
- D. Contact the client's family to provide support.
Correct Answer: B
Rationale: The priority action for the nurse is to assess the client's risk for suicide. By asking if the client has a plan to commit suicide, the nurse can determine the immediate safety of the client and take appropriate interventions to prevent harm. Administering antidepressant medication is not the first action to take in this situation as assessing the client's safety is the priority. Encouraging the client to attend a support group or contacting the client's family, although beneficial, are not immediate actions to ensure the client's safety in a crisis situation.
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A client with schizophrenia is prescribed an antipsychotic medication. Which of the following side effects should the nurse monitor for? Select one that does not apply.
- A. Tardive dyskinesia
- B. Neuroleptic malignant syndrome
- C. Mindfulness meditation
- D. Hyperglycemia
Correct Answer: C
Rationale: The correct answer is C, 'Mindfulness meditation.' Side effects of antipsychotic medications include tardive dyskinesia, neuroleptic malignant syndrome, orthostatic hypotension, and hyperglycemia. Mindfulness meditation is not a side effect of antipsychotic medications. Choices A, B, and D are all potential side effects of antipsychotic medications. Tardive dyskinesia is a movement disorder characterized by repetitive, involuntary movements. Neuroleptic malignant syndrome is a rare but life-threatening reaction to antipsychotic medication. Hyperglycemia can occur as a side effect of some antipsychotic medications, particularly the second-generation ones.
A client has been prescribed sertraline (Zoloft) for depression. Which of the following instructions should the nurse include in the discharge teaching?
- A. Take the medication in the morning to avoid daytime drowsiness.
- B. Avoid drinking alcohol while taking this medication.
- C. Take the medication with a full glass of water.
- D. Stop taking the medication if you feel better.
Correct Answer: B
Rationale: The correct instruction for the nurse to include in the discharge teaching is to advise the client to avoid drinking alcohol while taking sertraline (Zoloft). Alcohol can exacerbate the side effects of the medication, such as drowsiness and dizziness, and may also decrease the effectiveness of the treatment for depression. Choice A is incorrect as sertraline is usually taken in the morning. Choice C is not a specific instruction related to the medication. Choice D is incorrect as abruptly stopping sertraline can lead to withdrawal symptoms and should only be done under medical supervision.
What intervention should the nurse implement for a client with obsessive-compulsive disorder (OCD) performing ritualistic handwashing?
- A. Allow the client to continue the ritualistic behavior initially
- B. Immediately stop the client from performing the ritual
- C. Encourage the client to perform the ritual more quickly
- D. Provide a distraction to interrupt the ritual
Correct Answer: A
Rationale: For a client with OCD performing ritualistic handwashing, the nurse should initially allow the client to continue the behavior. Abruptly stopping the behavior or providing a distraction can heighten the client's anxiety. Encouraging the client to perform the ritual more quickly does not address the underlying issue of OCD and may exacerbate their anxiety. Providing a distraction to interrupt the ritual may not be effective in the long term and could lead to increased distress. Gradual limits should be established over time to help the client manage and reduce the ritualistic behavior effectively.
A healthcare professional is assessing a client with bipolar disorder who is experiencing a depressive episode. Which of the following findings should the healthcare professional expect? Select one that does not apply.
- A. High energy
- B. Feelings of hopelessness
- C. Insomnia or hypersomnia
- D. Decreased appetite
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which of the following are symptoms of a panic attack? Select one that does not apply.
- A. Chest pain
- B. Normal breathing
- C. Dizziness
- D. Hot flashes
Correct Answer: B
Rationale: Symptoms of a panic attack can include chest pain, shortness of breath, dizziness, and hot flashes. Normal breathing is not a symptom of a panic attack; instead, individuals experiencing a panic attack may often exhibit rapid or shallow breathing patterns. Therefore, the correct answer is B. Choices A, C, and D are typical symptoms associated with panic attacks, making them incorrect answers.