Nursing Elites

1. A nurse is providing discharge teaching to a client with major depressive disorder who is prescribed fluoxetine (Prozac). What is the most important teaching point for the nurse to include?

• A. You may experience dizziness, so avoid driving.
• B. It may take several weeks to feel the full effect of the medication.
• C. Avoid foods high in tyramine while taking this medication.
• D. Take this medication only when you feel depressed.

Correct answer: B

Rationale: The correct answer is B because SSRIs like fluoxetine typically take several weeks to reach their full therapeutic effect, so it's important to set realistic expectations for the client. Choice A is incorrect as dizziness is a common side effect but not the most important teaching point. Choice C is incorrect as avoiding tyramine-rich foods is more relevant for MAOIs. Choice D is incorrect as fluoxetine should be taken consistently, not only when the client feels depressed, to maintain therapeutic blood levels.

2. A nurse notes that a depressed female client has been more withdrawn and less communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

• A. Engage the client in non-threatening conversations.
• B. Schedule a daily conference with the social worker.
• C. Encourage the client's family to visit more often.
• D. Encourage the client to participate in group activities.

Correct answer: D

Rationale: The correct answer is to encourage the client to participate in group activities. Group activities can help improve social interaction and potentially reduce feelings of isolation in depressed clients. Choice A, engaging the client in non-threatening conversations, may be helpful but may not address the underlying need for social interaction that group activities can provide. Scheduling a daily conference with the social worker (Choice B) may not directly address the client's need for social engagement. Encouraging the client's family to visit more often (Choice C) is important for support but may not provide the same level of social interaction as group activities.

3. The LPN/LVN calls security and has physical restraints applied when a client who was admitted voluntarily becomes both physically and verbally abusive while demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select one that does not apply.

• A. false imprisonment
• B. Battery
• C. Assault
• D. Slander

Correct answer: D

Rationale: In this scenario, the possible legal ramifications for the nurse could include battery, assault, and false imprisonment. Battery refers to the intentional harmful or offensive touching of another person without consent, which could be perceived when applying physical restraints. Assault is the apprehension of harmful or offensive contact, creating fear in the individual, which can result from the verbal threats and physical actions of the patient. False imprisonment occurs when a person is unlawfully restrained, which may apply if the patient was involuntarily restrained. Slander, on the other hand, is the oral defamation of character, which does not align with the actions described in the scenario, making it the choice that does not apply.

4. An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is the most effective way for the nurse to assist this client?

• A. Plan an outing within the second week of admission.
• B. Distract the client whenever they express discomfort about being with others.
• C. Confront the client's fears and discuss the possible causes of these fears.
• D. Accompany the client outside for an increasing amount of time each day.

Correct answer: D

Rationale: The most effective way to assist a client with a fear of people and open places is through gradual desensitization by controlled exposure to the situation which is feared (D). This method helps the client confront their fears in a safe and supportive manner, allowing them to gradually build confidence and reduce anxiety. Planning an outing within the second week of admission (A) may be too soon and overwhelming for the client. Distracting the client whenever they express discomfort (B) does not address the underlying issue and may promote denial. Confronting the client's fears and discussing possible causes (C) could be too aggressive initially and may not be well-tolerated by the client.

5. What is the most important nursing intervention during the first 48 hours for a client with anorexia nervosa admitted to the hospital?

• A. Providing high-calorie, high-protein meals.
• B. Monitoring vital signs and electrolytes.
• C. Encouraging the client to talk about feelings.
• D. Observing for signs of purging.

Correct answer: B

Rationale: The most important nursing intervention during the first 48 hours for a client with anorexia nervosa is monitoring vital signs and electrolytes (B) to assess for life-threatening complications. This helps in early detection of any physiological imbalances that could lead to serious consequences. Providing high-calorie, high-protein meals (A) is important for nutritional rehabilitation but comes after ensuring the client's physical stability. Encouraging the client to talk about feelings (C) and observing for signs of purging (D) are relevant aspects of care but are not as critical as monitoring vital signs and electrolytes in the initial phase of treatment.

Similar Questions