Nokea
If the nurse notes the following symptoms after the client begins taking sertraline (Zoloft), which one is most likely drug-related?
- A. Polyuria
- B. Diplopia
- C. Drooling
- D. Insomnia
Correct Answer: D
Rationale: Insomnia is a common side effect of sertraline, an SSRI, due to its activating effects on the central nervous system.
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Staff members have expressed fear of the client who has a history of violent behavior. Which response made by the lead nurse would be most beneficial in addressing the staff’s expressed concerns?
- A. “Let’s not prejudge him. His medication should help him control his behavior.”
- B. “I will be very attentive to his behavior monitoring it for any signs of escalation.”
- C. “It may be hard but we need to appear calm and nonthreatening but alert to his behavior.”
- D. “As staff we are all trained to manage violent clients and we can handle any crisis behavior.”
Correct Answer: C
Rationale: Appearing calm and nonthreatening (C) addresses staff concerns and guides management. Prejudging (A) personal monitoring (B) or overconfidence (D) dismiss staff fears.
When interacting with a client experiencing a panic attack, which technique by the nurse is most likely to help reduce the client's anxiety level?
- A. Stand less than an arm's length away.
- B. State that everything is going to be okay.
- C. Instruct the client to take shallow breaths.
- D. Explain all actions and procedures.
Correct Answer: D
Rationale: Explaining actions provides predictability, reducing anxiety by enhancing the client's sense of control during a panic attack.
The client with a history of poly substance abuse is being medically detoxified in an acute care hospital. The client reported recently using alcohol oxycodone crack cocaine and marijuana. In planning for detoxification which substance for detoxification should be the nurse’s priority?
- A. Alcohol
- B. Marijuana
- C. Oxycodone
- D. Crack cocaine
Correct Answer: A
Rationale: Alcohol (A) has the most severe potentially fatal withdrawal. Marijuana (B) oxycodone (C) and cocaine (D) are less life-threatening.
The client who is addicted to cocaine states “I don’t really need treatment. Things just got a little out of hand causing some problems. I can handle things on my own. I really need to get back to my business.” Which response by the nurse best assists the client to break through denial and get insight into the severity of the addiction?
- A. “Tell me more about the business you feel you must return to at this time.”
- B. “You don’t really need to be here? Tell me more about what you are thinking.”
- C. “You don’t feel you need treatment. How often have you been using cocaine?”
- D. “You say you can handle things but you found yourself with a lot of problems.”
Correct Answer: D
Rationale: Confronting denial with problems (D) builds insight. Business (A) or usage (C) shifts focus parroting (B) risks defensiveness.
When the older client with Alzheimer's disease is confused about how to use a fork, which nursing action is best for prolonging an ability to maintain self-care?
- A. Ask the physician to order a liquid diet.
- B. Position the client to promote mimicking other clients.
- C. See the client first so there is sufficient time to eat.
- D. Seat the client alone so no one will see any mess that occurs.
Correct Answer: B
Rationale: Mimicking others leverages social cues, encouraging independent eating and prolonging self-care abilities.