Nursing Elites

1. A client with postpartum depression receives a prescription for sertraline (Zoloft). What information is most important to include in client teaching?

• A. Avoid foods high in tyramine, such as processed meats, red wine, and Swiss cheese.
• B. Contact the healthcare provider immediately if suicidal thoughts occur.
• C. Increase activity level to include regular exercise.
• D. Contact the healthcare provider immediately if muscle stiffness occurs.

Correct answer: B

Rationale: The most critical information to include in client teaching for a client with postpartum depression starting sertraline (Zoloft) is to contact the healthcare provider immediately if suicidal thoughts occur. This is vital for the client's safety as antidepressants, including sertraline, can sometimes increase the risk of suicidal thoughts, especially at the start of treatment. Choices A, C, and D are not the most crucial information in this scenario. Choice A about avoiding foods high in tyramine is not directly related to sertraline use. Choice C about increasing activity level is important but not as critical as addressing suicidal ideation. Choice D about muscle stiffness is a potential side effect of sertraline but is not as urgent as monitoring for suicidal thoughts.

2. During a group session on anger management, a male adolescent client is fidgety, interrupts peers, and talks about his pets at home. What action should the nurse take?

• A. Allow the client to leave and return in 10 minutes.
• B. Explore the client’s feelings about his pets and home life.
• C. Encourage his peers to help involve him in the activity.
• D. Redirect him by encouraging him to read from the handout.

Correct answer: D

Rationale: The best nursing action in this scenario is to redirect the client by encouraging him to read from the handout. This approach helps refocus the client's attention on the topic being discussed, which is anger management. Choice A is not appropriate as it may disrupt the group session and does not address the client's behavior. Choice B, while important in understanding the client's background, does not address the immediate disruptive behavior. Choice C involves others to manage the client's behavior instead of direct intervention by the nurse, which may not be effective in this situation.

3. A young adult male is hospitalized due to depression and an attempted suicide. The client reports that he lost his job and was angry with his employer for firing him when he took an overdose of pain medications. Which behavior best indicates to the nurse that his condition is improving?

• A. Initiates interactions with other clients.
• B. Describes verbally when he is angry.
• C. Participates in a job search with a social worker.
• D. Denies plans to harm himself or others.

Correct answer: A

Rationale: The best indicator of improvement in a client with depression is initiating interactions with others. This behavior demonstrates that the client is becoming less withdrawn and more self-directed, showing an improvement in social engagement and coping mechanisms. Choice B, describing anger verbally, may show some progress in emotional expression but does not necessarily indicate overall improvement in depression. Choice C, participating in a job search with a social worker, may be positive but does not directly address social interactions, which are crucial for improving depression. Choice D, denying plans to harm himself or others, is important for safety but does not directly reflect improvement in the client's social functioning or coping skills.

4. The healthcare provider documents the mental status of a female client who has been hospitalized for several days by court order. The client states, “I don’t need to be here” and tells the healthcare provider that she believes that the television talks to her. The healthcare provider should document these assessment findings in which section of the mental status exam?

• A. Level of concentration
• B. Insight and judgment
• C. Remote memory
• D. Mood and affect

Correct answer: B

Rationale: Insight and judgment should be documented as these findings assess the client’s awareness of their need for treatment and understanding of their condition. In this scenario, the client’s statement of not needing to be hospitalized and belief that the television talks to her reflect her insight into her situation and judgment regarding reality. The other options are incorrect: Level of concentration refers to the ability to focus and maintain attention; Remote memory evaluates the recall of past events and information; Mood and affect assess emotional state and expression, which are not directly reflected in the client's statements about her need for hospitalization and belief about the television.

5. A female client engages in repeated checks of door and window locks, behavior that prevents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take?

• A. Discuss why the client checks the locks frequently
• B. Ask the client why she checks the locks
• C. Plan a daily list of activities to be carried out
• D. Determine the type and size of the locks

Correct answer: B

Rationale: The correct action for the nurse to take is to ask the client why she checks the locks. By doing so, the nurse can help the client gain insight into the underlying anxiety that drives this behavior and assist her in developing new adaptive coping strategies. Choice A is not as effective as directly asking the client about her behavior. Choice C focuses on planning activities but does not address the root cause of the client's behavior. Choice D is irrelevant to addressing the client's repeated checking behavior.

Similar Questions