A nurse is caring for a client in the outpatient mental health clinic
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
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):
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Increased headaches: The client reports experiencing more frequent headaches, which can be an adverse effect of fluoxetine.
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Difficulty sleeping (hypersomnia): The client reports difficulty sleeping despite feeling less fatigued, which could be related to the medication's effect on sleep patterns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Infants with heart failure may tire easily during feedings, so limiting oral feedings to 30 minutes helps prevent excessive fatigue and ensures they are able to feed effectively without becoming overtired.
B. Incorrect. This is not frequent enough for an infant with heart failure. Oxygen saturation should be monitored more frequently, such as every 1-2 hours or as indicated by the clinical situation, to ensure adequate oxygenation and detect any changes promptly.
C. Incorrect. Weighing the infant daily is more appropriate to monitor fluid balance and heart failure progression.
D. Incorrect. Placing the infant in the prone position is contraindicated due to the risk of compromising respiratory function.
Correct Answer is B
Explanation
A. Incorrect. Sitting on the bed next to the client may infringe on the client's personal space and comfort.
B. Correct. Sitting in a chair next to the bed at the client's eye level helps establish a more comfortable and empathetic interaction.
C. Incorrect. Standing at the side of the bed may be perceived as less engaging and could create a power dynamic.
D. Incorrect. Standing at the foot of the bed may be uncomfortable for the client and may impede effective communication.
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