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When developing the plan of care for a client who is receiving lithium therapy, which nursing diagnosis would the nurse most likely identify as a priority?
- A. Self-Care Deficit
- B. Disturbed Sleep Pattern
- C. Imbalanced Nutrition: Less Than Body Requirements
- D. Imbalanced Fluid Volume
Correct Answer: D
Rationale: Imbalanced fluid volume is a priority due to lithium's narrow therapeutic index, where fluid status directly impacts toxicity risk.
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A client is prescribed a monoamine oxidase inhibitor (MAOI) for depression. During the initial interview, with the client, the nurse understands that the client is also receiving an adrenergic agent. The nurse would be alert for which of the following?
- A. Increased risk for hypertensive episodes
- B. Increased risk for severe convulsions
- C. Increased risk for hyperpyretic episodes
- D. Increased risk for cardiac arrhythmias
Correct Answer: D
Rationale: MAOIs combined with adrenergic agents can lead to cardiac arrhythmias due to excessive catecholamine activity.
Before administering an antidepressant to a client, which of the following would the nurse assess?
- A. Vital signs
- B. Presence of suicidal ideation
- C. Complete medical history
- D. Weight
- E. Mental status
Correct Answer: A,B,C,D,E
Rationale: A comprehensive assessment including vital signs, suicidal ideation, medical history, weight, and mental status is critical to ensure safe antidepressant administration.
A nurse is caring for an older adult client who has been prescribed amoxapine for depression accompanied by anxiety. After administration of the drug, the nurse observes muscle rigidity and sweating. The nurse identifies these as the symptoms of neuroleptic malignant syndrome. Which of the following would the nurse do next?
- A. Suggest the client engage in exercise
- B. Get the client to drink a glass of cold water
- C. Encourage the client to breathe deeply
- D. Stop the drug and contact the physician
Correct Answer: D
Rationale: Neuroleptic malignant syndrome is a medical emergency; stopping the drug and contacting the physician is the appropriate action.
A nurse caring for a client taking amitriptyline for depression should monitor the client for which of the following adverse events?
- A. Sedation
- B. Diarrhea
- C. Incontinence
- D. Dry mouth
- E. Photosensitivity
Correct Answer: A,D,E
Rationale: Tricyclic antidepressants like amitriptyline commonly cause sedation, dry mouth, and photosensitivity as side effects due to their anticholinergic and antihistaminic properties.
A nurse is caring for a client who has been prescribed a monoamine oxidase inhibitor (MAOI). Which of the following should the nurse instruct the client to avoid?
- A. Milk
- B. Butter
- C. Rice
- D. Yogurt
Correct Answer: D
Rationale: Yogurt contains tyramine, which can interact with MAOIs to cause hypertensive crisis; milk, butter, and rice are safe.