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When teaching a client about the side effects of fluoxetine (Prozac), which of the following will the nurse include?
- A. Tachycardia, blurred vision, hypotension, anorexia
- B. Orthostatic hypotension, vertigo, reactions to tyramine-rich foods
- C. Diarrhea, dry mouth, weight loss, reduced libido
- D. Photosensitivity, seizures, edema, hyperglycemia
Correct Answer: C
Rationale: Diarrhea, dry mouth, weight loss, reduced libido. Commonly reported side effects for fluoxetine (Prozac) are diarrhea, dry mouth, weight loss and reduced libido.
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Vital signs
Temperature 99.2 F (37.3 C)
Blood pressure 134/89 mm Hg
Heart rate 98/min
Respirations 19/min
Oz saturation (SpO) 99%
Sedation Awake, alert
A client reports 7 of 10 on the pain scale at 2300 and asks if it is too soon to receive 'another pain pill.' The nurse reviews the medication administration record. Which intervention should the nurse implement?
- A. Administer the hydrocodone/acetaminophen as prescribed
- B. Call the health care provider to request a prescription for a different analgesic
- C. Decrease the dose of hydrocodone/acetaminophen from 2 tablets to 1
- D. Prepare to administer naloxone
Correct Answer: A
Rationale: Pain rated 7/10 warrants administration of the prescribed analgesic if within the dosing interval. No indications suggest overdose (naloxone) or need for a different medication. Reducing the dose may inadequately manage pain.
The nurse is experiencing repeated unwanted sexual advances from a health care provider (HCP). Which of the following actions should the nurse take? Select all that apply.
- A. Seek emotional support from a trusted source.
- B. Consult the facility's sexual harassment policy.
- C. Report the behavior to the supervisor immediately.
- D. Document each occurrence according to facility policy.
- E. Confront the HCP outside the workplace about the behavior.
Correct Answer: A,B,C,D
Rationale: Seeking support aids coping, reviewing policy clarifies procedures, reporting to a supervisor initiates formal action, and documentation provides evidence. Confronting outside work risks escalation and is unsafe.
Which nursing diagnosis is least likely to apply to the client admitted with a diagnosis of borderline personality disorder?
- A. Risk for self-injury
- B. Identity disturbance
- C. Self-esteem disturbance
- D. Sensory-perceptual alteration
Correct Answer: D
Rationale: Borderline personality disorder is characterized by self-injury, identity issues, and low self-esteem, making A, B, and C relevant. Sensory-perceptual alteration is more associated with psychotic disorders, so D is least likely.
The nurse is planning care for a group of senior citizens. The nurse should plan activities that promote achievement of which developmental task?
- A. Identity
- B. Intimacy
- C. Generativity
- D. Ego integrity
Correct Answer: D
Rationale: Ego integrity, accepting one's life as meaningful, is the developmental task for seniors per Erikson's theory. Identity, intimacy, and generativity apply to younger stages.
The nurse is explaining the effects of cocaine abuse to a pregnant client. Which of the following must the nurse understand as a basis for teaching?
- A. Cocaine use can cause fetal growth retardation
- B. The drug has been linked to neural tube defects
- C. Newborn withdrawal generally occurs immediately after birth
- D. Breast feeding promotes positive parenting behaviors
Correct Answer: A
Rationale: Cocaine is vasoconstrictive, and this effect in the placental vessels causes fetal growth retardation.