Nokea
The nurse has received a new prescription for the client to begin taking sertraline. Prior to administering the initial dose of sertraline, it is most important for the nurse to obtain which information?
- A. Any history of heart disease
- B. Familial history of mental illness
- C. Medication history
- D. Current weight
Correct Answer: C
Rationale: Obtaining a thorough medication history is essential to identify potential drug interactions, allergies, or contraindications for sertraline. Heart disease history is relevant but less critical. Familial mental illness history is not immediately necessary. Weight does not typically affect sertraline dosing.
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Which individual should the nurse consider at highest risk for suicide?
- A. A retired older male whose significant other has passed away
- B. A nurse who works in a pediatric emergency department
- C. An adolescent male whose parents recently divorced
- D. A single working mother with three pre-school aged children
Correct Answer: C
Rationale: Adolescents experiencing significant life changes like parental divorce are at increased suicide risk due to emotional upheaval and limited coping skills. Older males may have coping mechanisms. Stressful jobs or parenting are less specific risk factors without additional context.
A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?
- A. Ineffective sexual patterns
- B. Disturbed sensory perception
- C. Compromised family coping
- D. Impaired environmental interpretation
Correct Answer: B
Rationale: The client's delusions (e.g., being married to a movie star, brother's intentions) indicate disturbed sensory perception, suggestive of psychosis, which is the priority. Ineffective sexual patterns are not directly indicated. Family coping may be secondary. Impaired environmental interpretation is too broad.
A client who has agoraphobia is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?
- A. Establish trust by providing a calm, safe environment
- B. Encourage deep breathing when anxiety escalates in a crowd
- C. Progressively expose the client to larger crowds
- D. Encourage substitution of positive thoughts for negative ones
Correct Answer: A
Rationale: Establishing trust through a calm, safe environment is foundational for effective desensitization in agoraphobia, supporting the client's sense of security. Deep breathing and positive thoughts are secondary. Progressive exposure comes after trust is established.
The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?
- A. Stimulation and dilated pupils
- B. Bradycardia and bradypnea
- C. Hallucinations and delusions
- D. Lethargy and depression
Correct Answer: A
Rationale: Cocaine use typically results in stimulation of the central nervous system, leading to increased heart rate, dilated pupils, and heightened alertness. Bradycardia and bradypnea are not typical, as cocaine causes tachycardia and increased respiratory rate. Hallucinations and delusions are more associated with hallucinogens or psychotic disorders. Lethargy and depression occur during the 'crash' phase, not the immediate effects of cocaine use.
The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?
- A. Alert the assigned staff to closely monitor client and intervene as needed to reduce risk of self-mutilation
- B. Provide the client time alone in the client's room to reduce external stimulation and promote relaxation
- C. Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed
- D. Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm
Correct Answer: A
Rationale: Alerting staff to monitor the client closely addresses the immediate risk of self-harm indicated by increased tension and pacing. Time alone may increase risk. Setting expectations is important but not immediate. Room searches are preventive but not the priority during acute distress.