A nurse is assisting with the care for a newly admitted client who has major depressive disorder.

Exhibits

Select 1 condition and 1 client finding to fill in each blank in the following sentence (Separate using a comma).

The client is at risk for developing
dropdown
due to the Client's intake of
dropdown

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

The client is at risk for developing Serotonin syndrome due to the Client's intake of St. John's wort

Explanation:

St. John's wort is an herbal supplement that can interact with certain medications, including selective serotonin reuptake inhibitors (SSRIs) and other medications that increase serotonin levels. Serotonin syndrome is a potentially life-threatening condition characterized by an excess of serotonin in the body.

In the given scenario, the nurse should identify:

Condition: The client's intake of St. John's wort

Client Finding: At risk for developing serotonin syndrome

This is because the use of St. John's wort, combined with medications that affect serotonin levels, increases the risk of serotonin syndrome. The nurse should monitor for symptoms of serotonin syndrome, such as changes in vital signs, hyperthermia, altered mental status, and neuromuscular abnormalities. If serotonin syndrome is suspected, medical attention should be sought promptly.

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Correct Answer is B

Explanation

Explanation:
A. While exercise can be beneficial for promoting sleep, suggesting it right before bedtime may not be the most practical advice, as vigorous exercise close to bedtime can sometimes have the opposite effect.

B. "Using alcohol for sleep can become problematic. Would you like to discuss other methods that might help you sleep?"
This response acknowledges the potential issue with using alcohol as a sleep aid and opens the door for further discussion about alternative methods to promote better sleep. Alcohol can disrupt sleep patterns and lead to dependency, so it's important for the nurse to address this concern and explore healthier sleep-promoting strategies.

C. Encouraging the use of alcohol as a way to "take the edge off" is not the best approach, as it may reinforce the client's reliance on alcohol for sleep, which can lead to dependency and other health issues.

D. Suggesting that the client speak with their provider about prescribing a sedative should not be the initial response. It's essential to explore non-pharmacological interventions and lifestyle changes before considering medications, especially sedatives, due to the potential for dependence and side effects.

A. it will help you feel better if you talk about it B. "Come on out and get involved with the game the other clients are playing C. "Til stay with you for a few minutes." D. Till come back when you feel like talking."

Correct Answer is C

Explanation

A. "It will help you feel better if you talk about it." While talking can be therapeutic, pushing the client to talk when they're not ready may be counterproductive and increase their distress.

B. "Come on out and get involved with the game the other clients are playing." Encouraging the client to engage in activities may not be suitable when she is expressing a need for solitude and is not ready to participate.

C. "I'll stay with you for a few minutes."
This response reflects the nurse's willingness to provide support without pressuring the client to talk. It acknowledges the client's feelings and offers a comforting and nonintrusive presence. It respects the client's desire for solitude while still showing empathy and availability.

D. "I'll come back when you feel like talking." This response leaves the client alone, which may
be appropriate if that's what the client prefers. However, offering to stay for a few minutes communicates immediate support without pressure.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who has chronic stress. The client states. i always feel so tired, but I can't sleep unless I have a cocktail or glass of wine at bedtime." Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, "I'm feeling sad. I don't want to talk now." Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who takes diazepam (Valium). Which of the following information should the nurse include?

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A nurse is caring for a client who has bipolar disorder and states that his latest computer project is "revolutionizing the industry." Which of the following behaviors is the client exhibiting?

A nurse overhears a client who has schizophrenia talking to herself. The client keeps stating "The muxtranks are coming. The muntranks are coming. The nurse correctly recognizes the client's use of the word mazuka as an example of which of the following alterations in speech?

A nurse is caring for a client who is prescribed alprazolam, a benzodiazepine for managing severe manifestations of anxiety. Which of the following should the nurse prepare to discuss with the client?

A nurse is caring for a client on an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?

A nurse is reinforcing teaching with a client who has a new prescription for fluoxetine. Which of the following instructions should the nurse Include?