A client with major depressive disorder has been taking fluoxetine, an SSRI, for 5 weeks. During the first outpatient visit, the client smiles and states, “I feel like a great weight is off my chest.” How should the nurse interpret this behavior change?

The client’s behavioral change is expected after the time period of medication.

The client may have worked out details of their suicide plan.

The medication dosage should be decreased and a mood stabilizer added.

The medication has potentiated serotonin syndrome.

Answer and Explanation

The Correct Answer is A

The correct answer is a. The client’s behavioral change is expected after the time period of medication.

Choice A Reason:

This choice is correct because fluoxetine, a selective serotonin reuptake inhibitor (SSRI), typically takes about 4 to 6 weeks to start showing its full effects. The client’s statement, “I feel like a great weight is off my chest,” indicates a positive response to the medication, which aligns with the expected timeline for SSRIs to improve mood and alleviate symptoms of depression. This behavioral change suggests that the medication is working as intended, helping to lift the depressive symptoms.

Choice B Reason:

This choice is incorrect and concerning. While it is true that some individuals may experience a temporary increase in energy before their mood improves, which could potentially increase the risk of suicide, the client’s positive statement does not necessarily indicate suicidal planning. It is important for healthcare providers to continuously monitor for any signs of suicidal ideation, but in this context, the client’s statement more likely reflects an improvement in their depressive symptoms.

Choice C Reason:

This choice is incorrect because there is no indication that the medication dosage should be decreased or that a mood stabilizer should be added. Fluoxetine is generally well-tolerated, and the client’s positive response suggests that the current dosage is effective. Mood stabilizers are typically used in the treatment of bipolar disorder, not major depressive disorder, unless there is a specific indication for their use.

Choice D Reason:

This choice is incorrect and indicates a misunderstanding of serotonin syndrome. Serotonin syndrome is a potentially life-threatening condition caused by excessive serotonin activity in the brain, often due to drug interactions or overdose. Symptoms include agitation, confusion, rapid heart rate, and high blood pressure4. The client’s statement of feeling relieved does not align with the symptoms of serotonin syndrome, which are generally severe and require immediate medical attention.

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Correct Answer is C

Explanation

d. Speaks another language and is in need of an interpreter to translate.

The correct answer is…

c. Is accompanied by a family member who will not let the client answer questions.

Choice A Reason:

The statement that the client is from another state and says they are here on a long vacation could be a sign of human trafficking, but it is not definitive. People often travel for various reasons, and being from another state does not necessarily indicate trafficking. However, if combined with other suspicious behaviors, it could raise concerns. Traffickers often move victims to different locations to avoid detection, but this alone is not enough to suspect trafficking.

Choice B Reason:

Having a cell phone that is not working in the emergency department might be suspicious, but it is not a strong indicator of human trafficking. There could be many reasons for a non-functioning cell phone, such as technical issues or lack of service. While traffickers might control victims’ communication devices, this alone does not provide enough evidence to suspect trafficking.

Choice C Reason:

Being accompanied by a family member who will not let the client answer questions is a strong indicator of human trafficking. Traffickers often pose as family members or friends to maintain control over their victims and prevent them from speaking freely. This behavior is a red flag because it suggests that the accompanying person is trying to control the interaction and possibly hide something. Healthcare providers are trained to recognize this as a potential sign of trafficking.

Choice D Reason:

Speaking another language and needing an interpreter to translate is not a strong indicator of human trafficking. Many people who are not victims of trafficking may speak different languages and require translation services. While language barriers can complicate communication, they are not in themselves indicative of trafficking. However, if combined with other suspicious behaviors, it could contribute to the overall assessment.

A. Assist the client to identify the triggering situation and choose a coping strategy. B. Send the client to the crisis intervention unit for 23 hours of observation. C. Restrain the client to prevent self-harm. D. Advise the client to take an anxiolytic to decrease their anxiety level.

Correct Answer is A

Explanation

Choice A Reason: Assist the client to identify the triggering situation and choose a coping strategy

This is the correct answer. Assisting the client to identify the triggering situation and choose a coping strategy is a therapeutic approach that empowers the client to understand and manage their emotions. This intervention helps the client develop skills to cope with distressing feelings and reduces the likelihood of self-harm. It is essential to address the underlying issues and provide support in a constructive manner.

Choice B Reason: Send the client to the crisis intervention unit for 23 hours of observation

While sending the client to a crisis intervention unit may be necessary in some cases, it is not the first step. Immediate therapeutic intervention to help the client understand and manage their emotions is crucial. Observation alone does not address the underlying issues or provide the client with coping mechanisms.

Choice C Reason: Restrain the client to prevent self-harm

Restraint should be a last resort and only used when there is an immediate risk of harm that cannot be managed through other means. It is important to first attempt less restrictive interventions that help the client manage their emotions and behaviors.

Choice D Reason: Advise the client to take an anxiolytic to decrease their anxiety level

While medication can be part of the treatment plan, it should not be the first intervention. Addressing the client’s immediate emotional needs and helping them develop coping strategies is crucial. Medication can be considered as part of a comprehensive treatment plan but should not replace therapeutic interventions.

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A client with major depressive disorder has been taking fluoxetine, an SSRI, for 5 weeks. During the first outpatient visit, the client smiles and states, “I feel like a great weight is off my chest.” How should the nurse interpret this behavior change?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a client who is malnourished and appears exhausted. What data would cause the nurse to suspect the client is a victim of human trafficking? The client:

Correct Answer is C

Explanation

Edited TextA client with borderline personality disorder reported to the nurse in the clinic that they feel empty and anxious. The client wants to cut their arms. The nurse should first:

Correct Answer is A

Explanation

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