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The nurse is caring for a client with a history of depression who is receiving sertraline (Zoloft) 50 mg PO daily. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue.
- B. Dry mouth.
- C. Suicidal thoughts.
- D. Insomnia.
Correct Answer: C
Rationale: Suicidal thoughts are a medical emergency in clients on SSRIs like sertraline. Options A, B, and D are common side effects.
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A nurse is doing preconception counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome?
- A. I understand that a glass of wine with dinner is healthy.
- B. Beer is not really hard alcohol, so I guess I can drink some.
- C. If I drink, my baby may be harmed before I know I am pregnant.
- D. Drinking with meals reduces the effects of alcohol.
Correct Answer: C
Rationale: If I drink, my baby may be harmed before I know I am pregnant. This reflects awareness of alcohol's early fetal risks.
The provisions of the law for the Americans with Disabilities Act require nurse managers to
- A. Maintain an environment free from associated hazards
- B. Provide reasonable accommodations for disabled individuals
- C. Make all necessary accommodations for disabled individuals
- D. Consider both mental and physical disabilities
Correct Answer: B
Rationale: The law is designed to permit persons with disabilities access to job opportunities. Employers must evaluate an applicant's ability to perform the job and not discriminate on the basis of a disability. Employers also must make 'reasonable accommodations.'
According to Erickson's stage of growth and development, the developmental task associated with middle childhood is:
- A. Trust
- B. Initiative
- C. Independence
- D. Industry
Correct Answer: D
Rationale: Middle childhood (ages 6-12) is associated with the developmental task of industry, where children focus on competence and achievement.
The nurse is caring for clients on the neurology unit.
- A. What is the most appropriate action for the nurse to take after noting a client suddenly developed a fixed and dilated pupil?
- B. Reassess in five minutes.
- C. Check the client’s visual acuity.
- D. Lower the head of the client’s bed.
- E. Contact the physician.
Correct Answer: D
Rationale: A fixed and dilated pupil is a neurological emergency, often indicating increased intracranial pressure or brain herniation. Immediate physician notification is critical to initiate interventions. Reassessing later delays care, checking visual acuity is irrelevant, and lowering the bed could worsen intracranial pressure.
Promethazine hydrochloride (Phenergan) 25 mg IV push has been ordered for a patient. Before administering this medication to the patient, the nurse should check the
- A. color of the medication solution.
- B. patient's pulse and temperature.
- C. time of the last analgesic dose the patient received.
- D. patency of the patient's vein.
Correct Answer: D
Rationale: is very important to determine absolute patency of the vein; extravasation will cause necrosis