The nurse is talking with a client with major depressive disorder who is receiving isocarboxazid. Which of the following statements by the client would be a priority to follow up?
- A. I am feeling fatigued at the end of most days.
- B. I have been experiencing constipation recently
- C. I have been gaining weight since I started taking the medication
Correct Answer: A
Rationale: Fatigue may indicate worsening depression or MAOI side effects, requiring urgent follow-up. Constipation and weight gain are common but less critical.
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The nurse is caring for a client who has gastroesophageal reflux disease and has been receiving long-term omeprazole therapy. The nurse should recognize that the client is at highest risk for developing
- A. jaw necrosis
- B. vision changes
- C. gait disturbance
- D. Clostridoides difficile infection
Correct Answer: D
Rationale: Long-term omeprazole increases risk of C. difficile due to altered gut flora. Jaw necrosis , vision changes , and gait disturbance are not associated.
The nurse is caring for a client recovering from a fracture. Which diet selection would be best for this client?
- A. Fried chicken, a loaded baked potato, and tea
- B. Dressed cheeseburger, French fries, and soda
- C. Tuna fish salad on sourdough bread, potato chips, and skim milk
- D. Broiled chicken, Mandarin orange salad, and milk
Correct Answer: D
Rationale: A diet rich in protein, calcium, and vitamins supports bone healing. Broiled chicken, Mandarin orange salad, and milk provide these nutrients. Options A, B, and C include less nutrient-dense foods like fried items or chips, making them less ideal.
A client with generalized anxiety disorder has received a new prescription for sertraline. The nurse should reinforce teaching to the client on what possible adverse effect?
- A. Hypernatremia
- B. Sexual dysfunction
- C. Urinary retention
- D. Weight loss
Correct Answer: B
Rationale: Sertraline commonly causes sexual dysfunction, a significant side effect. Hypernatremia , urinary retention , and weight loss are less common.
The nurse is preparing to obtain a urine specimen for urinalysis from an 18-month-old client. Which of the following actions should the nurse take?
- A. Perform intermittent straight catheterization to obtain the urine from the client.
- B. Apply an adhesive urine collection bag around the client's genital area.
- C. Ask the parent to obtain the client's urine using a specimen cup
- D. Place a urine dipstick in the client's diaper overnight.
Correct Answer: B
Rationale: An adhesive collection bag is non-invasive and effective for toddlers. Catheterization is invasive, a cup is impractical, and a dipstick is inaccurate.
The nurse is monitoring a client during the dwell time of a peritoneal dialysis cycle. Which of the following findings would require immediate follow-up?
- A. reports of intermittent nausea
- B. crackles in the lung bases bilaterally
- C. 1+ pitting edema of the ankles and feet bilaterally
- D. blood pressure of 108/88 mm Hg and heart rate of 72/min
Correct Answer: B
Rationale: Crackles suggest fluid overload, a serious dialysis complication. Nausea , mild edema , and normal BP/HR are less urgent.
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