A nurse is caring for a client in the outpatient mental health clinic

exhibits

Click to highlight the findings that indicate the client is experiencing adverse effects of the medication. To deselect a finding, click on the finding again
Nurses' Notes
Today

Client states "I’m feeling much better." They report less fatigue even though they have difficulty sleeping. Client reports they are not sad anymore but are experiencing more frequent headaches. Client continues to deny any suicidal ideation

Vital Signs
Today
BP 149/91 mm Hg

Heart rate 75min

Respiratory rate 18/min

difficulty sleeping

frequent headaches

feeling much better

less fatigue

Answer and Explanation

The Correct Answer is ["A","B"]

Client states "I’m feeling much better." They report less fatigue even though they have difficulty sleeping. Client reports they are not sad anymore but are experiencing more frequent headaches. Client continues to deny any suicidal ideation
Vital Signs
Today
BP 149/91 mm Hg

Heart rate 75min

Respiratory rate 18/min

Explanation:

Based on the provided information, the following findings indicate the client may be experiencing adverse effects of the medication (fluoxetine):

Increased headaches: The client reports experiencing more frequent headaches, which can be an adverse effect of fluoxetine.
Difficulty sleeping (hypersomnia): The client reports difficulty sleeping despite feeling less fatigued, which could be related to the medication's effect on sleep patterns.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Incorrect. Providing oral hygiene care is important but not the first priority after a client has vomited

B. Incorrect. While administering an antiemetic medication might be considered, providing oral hygiene care to the client is the immediate priority.

C. Incorrect. Replacing the NG tube is not typically the first action to take after a client vomits. Addressing oral hygiene and assessing the client's condition comes first.

D. Correct. Evaluating the functioning of the suction device is important as it helps to prevent aspiration of contents.

A. Initiate seclusion protocol. B. Tell the client, "You seem to be very upset." C. Use a face shield with a mask when providing care to the client. D. Engage the panic alarm.

Correct Answer is B

Explanation

A. Incorrect. Initiating seclusion protocol should only be done in situations where the safety of the client or others is at risk and after appropriate assessment and intervention.

B. Correct. Acknowledging the client's emotions and showing empathy can help defuse the situation and promote effective communication.

C. Incorrect. Using personal protective equipment (face shield with mask) is not necessary when interacting with an agitated client unless there is a specific infection control concern.

D. Incorrect. Engaging the panic alarm is not necessary in this situation, as it may escalate the client's agitation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first?

Correct Answer is D

Explanation

A nurse is teaching a newly licensed nurse about caring for clients in the emergency department. Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?

Correct Answer is B

Explanation

A nurse is planning care for a toddler who has epiglottitis. Which of the following interventions should the nurse include?

A nurse is performing postmortem care for a recently deceased client prior to the client's family visit. Which of the following actions should the nurse plan to take?

A staff nurse is observing a newly licensed nurse suction a client's tracheostomy. Which of the following actions by the newly licensed nurse requires intervention by the staff nurse?

A nurse is providing discharge teaching to a client who has a new ostomy. Which of the following instructions should the nurse include?

A nurse is providing discharge teaching to a client who has GERD.Which of the following information should the nurse include?

A nurse is caring for a client who presents to the emergency department. Exhibits A nurse is reviewing the client's record. Which of the following client findings indicate the need for further evaluation? (Select All that Apply.)

A nurse is assessing a client who has an abdominal incision. Which of the following findings should the nurse report to the provider?

A nurse is planning care for a client who has a history of urinary tract infections (UTIs) and requires placement of an indwelling urinary catheter.Which of the following actions should the nurse take to help minimize the client's risk for acquiring a UTI?