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A client diagnosed with major depressive disorder is prescribed an SSRI. Which side effect should the nurse monitor for in the initial weeks of treatment?
- A. Weight loss
- B. Increased risk of suicide
- C. Hypertension
- D. Photosensitivity
Correct Answer: B
Rationale: When a client is prescribed an SSRI for major depressive disorder, the nurse should closely monitor for an increased risk of suicide, especially in younger patients, during the initial weeks of treatment. SSRIs may initially increase energy levels before improving mood, which can lead to a higher risk of suicide in some individuals. Weight loss is not a common side effect of SSRIs and may actually be a concern for some patients with major depressive disorder who experience appetite changes. Hypertension is not typically associated with SSRIs, and photosensitivity is not a common side effect of this class of medications.
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A client has been prescribed bupropion (Wellbutrin) for depression. Which instruction should the nurse provide during discharge?
- A. Take the medication with a full glass of water.
- B. Stop taking the medication if you feel better.
- C. Avoid drinking alcohol while taking this medication.
- D. Double the dose if you miss a dose.
Correct Answer: C
Rationale: The correct instruction for the nurse to provide is to advise the client to avoid drinking alcohol while taking bupropion (Wellbutrin) due to the increased risk of side effects like seizures. Alcohol can interact with bupropion and worsen its side effects, making it important to abstain from alcohol consumption during the treatment. Option A is incorrect because taking the medication with a full glass of water is a general instruction for medications and not specific to bupropion. Option B is incorrect as abruptly stopping bupropion can lead to withdrawal symptoms and should only be done under medical supervision. Option D is incorrect as doubling the dose of bupropion is dangerous and should not be done, even if a dose is missed.
When assessing a client experiencing severe anxiety, which symptom should the nurse expect to observe?
- A. Restlessness
- B. Rapid heart rate
- C. Sweating
- D. Dry mouth
Correct Answer: B
Rationale: When a client is experiencing severe anxiety, a rapid heart rate is a common physiological response. This increased heart rate is due to the body's fight-or-flight response, where adrenaline is released, causing the heart to beat faster. Monitoring the client's heart rate is crucial in assessing and managing their anxiety. Restlessness (choice A) can also be present in anxiety but is more of a behavioral manifestation rather than a physiological symptom. Sweating (choice C) can occur in anxiety, but it is not as specific or consistent as a rapid heart rate. Dry mouth (choice D) is associated with anxiety but is not as immediate or directly linked to the body's physiological response to stress as a rapid heart rate.
A client is prescribed lorazepam (Ativan) for the management of anxiety. Which statement by the client indicates the need for further teaching?
- A. I should take this medication at the same time every day.
- B. I can drink alcohol while taking this medication.
- C. I should avoid driving while taking this medication.
- D. I should avoid using this medication during pregnancy.
Correct Answer: B
Rationale: The correct answer is B. Clients should avoid alcohol while taking lorazepam (Ativan) due to potential interactions. Alcohol can increase the side effects of lorazepam, such as drowsiness and dizziness, which can be dangerous, especially when combined with activities like driving or operating machinery. Choice A is correct as it promotes medication adherence. Choice C is correct as lorazepam can impair cognitive and motor skills, impacting driving ability. Choice D is correct as lorazepam is not recommended during pregnancy due to potential harm to the fetus.
A client diagnosed with paranoid schizophrenia states, 'The FBI is watching me. I see their agents everywhere.' Which is the nurse's most appropriate response?
- A. You shouldn't worry about that. It's not real.
- B. I don't see any FBI agents, but it sounds like you're feeling frightened.
- C. Let's talk about something else to take your mind off of it.
- D. Why do you think the FBI is watching you?
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client diagnosed with generalized anxiety disorder (GAD) states, 'I just can't stop worrying about everything.' Which nursing diagnosis is most appropriate for this client?
- A. Ineffective coping
- B. Disturbed thought processes
- C. Chronic low self-esteem
- D. Social isolation
Correct Answer: A
Rationale: The most appropriate nursing diagnosis for a client with generalized anxiety disorder (GAD) who expresses an inability to stop worrying about everything is 'Ineffective coping.' This diagnosis indicates the client's struggle to manage anxiety and worry effectively, which aligns with the client's statement. 'Disturbed thought processes' (Choice B) would involve disorganized or irrational thinking patterns, which are not directly related to the client's statement about excessive worry. 'Chronic low self-esteem' (Choice C) refers to a long-standing negative self-evaluation and is not the most fitting diagnosis for the client's current concern. 'Social isolation' (Choice D) pertains to a lack of social interactions and support, which is not the primary issue highlighted by the client's statement.