Nokea
Following treatment with fluoxetine, a selective serotonin reuptake inhibitor for depression, Mary hardly sleeps, is hyperactive, easily distracted, and appears elated. You would expect her physician to
- A. Continue the selective serotonin reuptake inhibitor.
- B. Start a mood stabilizer.
- C. Switch to a tricyclic antidepressant.
- D. Add a monoamine oxidase inhibitor.
Correct Answer: B
Rationale: Mood stabilizers are used to treat symptoms of mania or hypomania associated with bipolar disorder.
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A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
- A. Insert an indwelling urinary catheter.
- B. Inspect the mouth for signs of inhalation injuries.
- C. Administer intravenous pain medication.
- D. Draw blood for a complete blood cell (CBC) count.
Correct Answer: B
Rationale: The correct answer is B: Inspect the mouth for signs of inhalation injuries. This is the priority action because inhalation injuries can be life-threatening due to airway compromise. The nurse should assess for soot in the mouth, facial burns, hoarseness, and difficulty breathing. This allows for prompt intervention if respiratory distress is present.
A: Inserting an indwelling urinary catheter is not the priority as it does not address the immediate life-threatening issue.
C: Administering pain medication is important but not the priority over assessing for inhalation injuries which could lead to respiratory distress.
D: Drawing blood for a CBC count is not the priority as it does not address the immediate threat to the client's airway.
During the rehabilitation of a patient with limited mobility, how can decubitus ulcers be prevented?
- A. Turning the patient every 4 hours
- B. Using a heat lamp on reddened areas
- C. Applying vitamin C to bony prominences
- D. Keeping the skin clean, dry, and well lubricated
Correct Answer: D
Rationale: Maintaining skin integrity through cleanliness and moisture management prevents pressure ulcers.
A client is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?
- A. Pain severity
- B. Wound drainage
- C. Tissue integrity
- D. Airway patency
Correct Answer: D
Rationale: The correct answer is D: Airway patency. Assessing airway patency is the priority in the immediate postoperative period following a laryngectomy to ensure the client's ability to breathe. If the airway is compromised, it can lead to life-threatening complications. Pain severity (A), wound drainage (B), and tissue integrity (C) are important assessments but are secondary to ensuring the client's airway is clear and functioning properly. Prioritizing airway patency allows for prompt intervention if any issues arise, ensuring the client's safety and optimal recovery.
Before administering a benzodiazepine, what should the nurse assess?
- A. Sleep problems
- B. Memory impairment
- C. Cognitive disorder
- D. Behavior changes
Correct Answer: D
Rationale: Behavioral changes may indicate underlying issues or contraindications for benzodiazepines.
What is the definition of substance abuse?
- A. A compulsive need to experience pleasure
- B. Behavior associated with maintaining an addiction
- C. Absence of a substance will cause withdrawal symptoms
- D. Overuse and dependence on a substance that negatively affects functioning.
Correct Answer: D
Rationale: Substance abuse involves overuse and dependence on a substance leading to negative impacts on one's life, encompassing both physical and social consequences.