Nokea
The nurse is caring for a client with a history of depression who is receiving venlafaxine (Effexor) 75 mg PO bid. 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 with venlafaxine. Options A, B, and D are common side effects.
You may also like to solve these questions
A woman has been recently diagnosed with systemic lupus and shares with the nurse, 'I am thinking about getting pregnant, but I don't know how I will be able to tolerate a pregnancy since I have lupus.'
- A. What is the best response by the nurse to a woman with systemic lupus considering pregnancy?
- B. Most women find that they feel better when they are pregnant.'
- C. How long have you been in remission?'
- D. Women with lupus frequently have slightly longer gestations.'
- E. It is best to become pregnant within the first six months of diagnosis.'
Correct Answer: B
Rationale: The nurse should assess the duration of remission, as women with systemic lupus erythematosus (SLE) should be in remission for at least 5 months before conceiving to minimize risks of maternal and fetal complications. Pregnancy does not typically improve SLE symptoms, gestation length is unaffected, and early pregnancy post-diagnosis is not recommended.
The nurse answers the psychiatric unit's desk phone. The caller identifies himself as the husband of a patient and inquires about her condition.
Which of the following responses by the nurse is MOST appropriate?
- A. I may not deny or confirm any patient's presence in this hospital.'
- B. Patients are not allowed to use this phone. Please call the patient's phone number directly.'
- C. I cannot give information over the phone. If you come in we can discuss her condition.'
- D. I will have to ask her if she wishes for me to give out that information.'
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) confidentiality prohibits a professional from discussing information about the patient (2) correct-psychiatric patient retains civil rights to communicate with outside world and have reasonable access to telephones (3) breaks confidentiality (4) patient able to speak for herself
Which instruction should be given to the client taking alendronate sodium (Fosamax)?
- A. Take the medication before arising.
- B. Force fluids while taking this medication.
- C. Remain upright for 30 minutes after taking this medication.
- D. Take the medication in conjunction with estrogen.
Correct Answer: C
Rationale: Alendronate sodium is a drug used to treat osteoporosis. The drug causes gastric reflux, so the client should remain upright for 30 minutes after taking it and take it with only water. Taking it before arising or with estrogen is incorrect, and forcing fluids is not necessary.
A client is in the third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority?
- A. Counsel the woman to consent to HIV screening
- B. Perform tests for sexually transmitted diseases
- C. Discuss her high risk for cervical cancer
- D. Refer the client to a family planning clinic
Correct Answer: A
Rationale: Counsel the woman to consent to HIV screening. The client's behavior places her at high risk for HIV. Testing is the first step to ensure early treatment if positive.
A client is admitted with acute abdominal pain. Which of the following findings would require immediate attention?
- A. BP 100/50, P 96, abdominal distention
- B. Temperature 99°, flatulence, nausea
- C. Urinary frequency and dysuria
- D. Temperature 99.2°, amber-colored urine
Correct Answer: A
Rationale: Hypotension (BP 100/50), tachycardia (P 96), and abdominal distention suggest a serious condition like internal bleeding or perforation, requiring immediate attention.