Nokea
While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse?
- A. How will this affect your present sexual activity?
- B. How active is your current sex life?
- C. How has your sex life changed as you have become older?
- D. Tell me about your sexual needs as an older adult.
Correct Answer: A
Rationale: The best response in this scenario is option A, 'How will this affect your present sexual activity?' This response directly addresses the client's concern and allows them to express their thoughts and feelings. Option B does not directly address the client's worry about the medication's side effect. Options C and D deviate from the client's immediate concern and are not as relevant in this situation.
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One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a female client tells the nurse, 'I think I will plan a big party for all my friends.' How should the nurse respond?
- A. 'You may not have enough energy before long to hold a big party.'
- B. 'Do you mean to say that you want to plan your funeral and wake?'
- C. 'Planning a party and thinking about all your friends sounds like fun.'
- D. 'You should be thinking about spending your last days with your family.'
Correct Answer: C
Rationale: Setting goals that bring pleasure is appropriate and should be encouraged by the nurse as long as the nurse does not perpetuate a client's denial. Option A is a negative response, implying that the client should not plan a party, which is not supportive. Option B is presumptive and may not reflect the client's true intentions. The correct response (Option C) acknowledges the client's positive plans and encourages her to enjoy her time with friends. Option D, while family is important, does not consider the client's wishes and choices, which should be respected and supported in this situation.
A client is being assessed by a nurse for increased anxiety, restlessness, and insomnia. Which of the following interventions is the first priority for the nurse?
- A. Administer anti-anxiety medications as prescribed by the healthcare provider
- B. Engage in a conversation with the client regarding methods to enhance rest and sleep
- C. Escort the client to a private room and stay with them
- D. Review the client's medical history to determine previous treatment for these issues
Correct Answer: C
Rationale: The first priority when dealing with a client experiencing potential mental health issues is to ensure their safety. Taking the client to a private room helps to reduce external stimuli and staying with them ensures constant monitoring and support. This intervention can prevent any escalation of anxiety or restlessness and promote a sense of security for the client. Engaging in a conversation about improving rest and sleep is important but ensuring immediate safety takes precedence. Administering medications should only be done after the client's safety is assured. Reviewing the client's medical history, while important, is not the immediate priority when the client is exhibiting acute symptoms of anxiety and restlessness.
An increase in the neurotransmitter dopamine is associated with which of the following illnesses?
- A. Schizophrenia
- B. Depression
- C. Alzheimer's disease
- D. Anxiety
Correct Answer: A
Rationale: An increase in the neurotransmitter dopamine is associated with schizophrenia. Dopamine dysregulation is linked to some symptoms of schizophrenia, such as hallucinations and delusions. Depression (choice B) is more commonly associated with abnormalities in serotonin and norepinephrine. Alzheimer's disease (choice C) is primarily characterized by deficits in acetylcholine and other neurotransmitters. Anxiety disorders (choice D) are often linked to imbalances in neurotransmitters like serotonin, norepinephrine, and GABA, rather than dopamine.
The nurse transcribes the postoperative prescriptions for a client who returns to the unit following surgery and notes that an antihypertensive medication that was prescribed preoperatively is not listed. Which action should the nurse take?
- A. Consult with the pharmacist about the need to continue the medication.
- B. Administer the antihypertensive medication as prescribed preoperatively.
- C. Withhold the medication until the client is fully alert and vital signs are stable.
- D. Contact the health care provider to renew the prescription for the medication.
Correct Answer: D
Rationale: In this scenario, the nurse has noted that an antihypertensive medication prescribed preoperatively is missing from the postoperative prescriptions. It is essential to renew preoperative medications postoperatively. Therefore, the correct action for the nurse to take is to contact the health care provider to renew the prescription for the antihypertensive medication. Consulting with the pharmacist about the need to continue the medication is not appropriate in this situation as pharmacists do not prescribe or renew medications. Administering the antihypertensive medication as prescribed preoperatively without a current prescription poses a risk to the client's safety. Withholding the medication until the client is fully alert and vital signs are stable does not address the issue of the missing prescription and delays the client's necessary treatment.
The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take?
- A. Review the chart for a signed consent for medication administration.
- B. Get the guardian's permission to give the medication.
- C. Do not give the medication and document the reason.
- D. Complete an incident report and notify the supervisor.
Correct Answer: C
Rationale: In this scenario, the correct action for the nurse to take is not to administer the medication and document the reason. Since the adolescent client is a minor, parental or guardian consent is required for medical treatment, including medication administration. Option A, reviewing the chart for a signed consent for medication administration, is not the appropriate action in this situation as the focus is on parental consent for the client. Option B is incorrect because obtaining the health care provider's permission does not replace the need for parental consent for a minor. Option D, completing an incident report and notifying the supervisor, is unnecessary as there is no adverse event to report; the key concern is the lack of parental consent for medication administration.