Nokea
Which of the following would the nurse report to the primary health care provider if assessed in a client receiving an antidepressant?
- A. Weight gain
- B. Expressions of guilt
- C. Indirect threats of suicide
- D. Somnolence
- E. Insomnia
Correct Answer: B,C,E
Rationale: Expressions of guilt, indirect suicide threats, and insomnia are concerning symptoms indicating potential worsening of depression or side effects requiring medical attention.
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A nurse determines the need to administer a prescribed antidepressant in the morning because of the increased likelihood of insomnia. Which drug would this most likely be?
- A. Amitriptyline
- B. Bupropion
- C. Citalopram
- D. Paroxetine
- E. Sertraline
Correct Answer: C,D,E
Rationale: SSRIs like citalopram, paroxetine, and sertraline are more likely to cause insomnia, making morning administration preferable.
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 client is receiving lithium therapy at a health care facility. The client informs the nurse that he is taking antacids for heartburn. The nurse would be alert for which of the following due to the interaction of the two drugs?
- A. Decreased effectiveness of lithium
- B. Increased risk of lithium toxicity
- C. Increased risk for bipolar disorder
- D. Increased psychotic symptoms
Correct Answer: A
Rationale: Antacids can reduce lithium absorption, leading to decreased effectiveness of the drug.
A client taking phenelzine (Nardil) is at a dinner party and has several glasses of red wine. The client begins to feel nauseated and develops a terrible headache. The client is taken to the nearest emergency department (ED). This client might be experiencing a hypertensive crisis. What other symptoms might the nurse in the ED assess if the client is experiencing a hypertensive crisis?
- A. Constricted pupils
- B. Chills
- C. Chest pain
- D. Tachycardia
- E. Stiff neck
Correct Answer: C,D,E
Rationale: Hypertensive crisis from MAOI-tyramine interactions may present with chest pain, tachycardia, and stiff neck, among other symptoms.
A client is prescribed lithium. The nurse suspects lithium toxicity based on which lithium drug level?
- A. 0.8mEq /L
- B. 1.0mEq /L
- C. 1.3mEq /L
- D. 1.6mEq /L
Correct Answer: D
Rationale: Lithium toxicity typically occurs at serum levels above 1.5 mEq/L, making 1.6 mEq/L indicative of toxicity.