Nokea
The nurse is talking with a client with major depressive disorder who has been taking paroxetine for the past 3 weeks. Which of the following statements by the client would require immediate follow-up?
- A. I have had a decreased appetite lately.'
- B. I still feel depressed even though I have more energy.'
- C. I sometimes have difficulty falling asleep at night.'
- D. I have had a decreased interest in sexual activity recently.'
Correct Answer: B
Rationale: Persistent depression with increased energy (B) may indicate rising suicide risk, requiring immediate follow-up. Appetite (A), sleep (C), and libido (D) changes are common side effects.
You may also like to solve these questions
The nurse is reinforcing teaching for a client with bipolar disorder who has a new prescription for lithium. Which of the following statements by the client would require follow-up?
- A. I should drink at least 2 to 3 L of fluid daily.'
- B. I can take over-the-counter ibuprofen for pain relief.'
- C. I will maintain a consistent dietary intake of sodium.'
- D. I should have my medication levels checked periodically.'
Correct Answer: B
Rationale: Ibuprofen (B) can increase lithium toxicity, requiring follow-up. Adequate fluid intake (A), consistent sodium (C), and periodic level checks (D) are correct.
A client with borderline personality disorder says to the nurse, 'You're the only one I trust around here. The others don't know what they are doing and they don't care about anyone except themselves. I only want to talk with you.' What is the priority nursing action?
- A. Assign different staff members to care for the client each day
- B. Assign the client's stated preferred nurse to care for the client
- C. Reassure the client that all staff members are competent in their jobs
- D. Reinforce unit guidelines and appropriate boundaries with the client
Correct Answer: D
Rationale: Reinforcing boundaries (D) addresses splitting behavior and maintains therapeutic relationships. Rotating staff (A), assigning the preferred nurse (B), or reassuring competence (C) may reinforce manipulation.
The nurse working on a pediatric oncology unit recognizes which as a personal coping strategy for remaining effective when caring for dying children?
- A. Attending a child's memorial service
- B. Avoiding expressing personal feelings of grief or loss directly with the family
- C. Ending personal contact with the deceased's family members after they leave the hospital
- D. Increasing length of daily exercise routines
Correct Answer: D
Rationale: Increasing exercise (D) is a healthy coping strategy to manage stress. Attending memorials (A), avoiding grief expression (B), or ending contact (C) may not promote long-term emotional resilience.
The nurse is caring for a client receiving chemotherapy. The client is prescribed filgrastim to improve the function of the immune system. Which finding does the nurse anticipate in response to the medication?
- A. Decrease in serum uric acid
- B. Increase in hemoglobin level
- C. Increase in neutrophil count
- D. Increase in platelet count
Correct Answer: C
Rationale: Filgrastim stimulates neutrophil production, so an increase in neutrophil count (C) is expected. It does not affect uric acid (A), hemoglobin (B), or platelets (D).
A client with a pyloric obstruction is admitted to the hospital with vomiting. Which of the following blood gases would the nurse expect to see in the client with vomiting?
- A. $\mathrm{pH} 7.33, \mathrm{PCO}_2 30 \mathrm{~mm} \mathrm{Hg}$
- B. $\mathrm{pH} 7.50, \mathrm{PCO}_2 32 \mathrm{~mm} \mathrm{Hg}$
- C. $\mathrm{pH} 7.30, \mathrm{PCO}_2 50 \mathrm{~mm} \mathrm{Hg$
- D. $\mathrm{pH} 7.47, \mathrm{PCO}_2 40 \mathrm{~mm} \mathrm{Hg}$
Correct Answer: B
Rationale: Vomiting causes loss of hydrochloric acid, leading to metabolic alkalosis, indicated by a high pH (7.50) and normal to low PCO2.