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 A

Explanation

A. Correct. At 12 weeks of gestation, the nurse should position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate.
B. Fundal height measurement is used to assess uterine growth and is not applicable for assessing fetal heart rate.
C. Placing the client in a side-lying position is not necessary for assessing fetal heart rate at 12 weeks of gestation.
D. Leopold maneuvers are used to determine fetal position and lie and are not directly related to auscultating the fetal heart rate.

A. Arrange for the nurses to have as few shifts together as possible. B. Encourage collaboration between the two nurses when making assignments. C. Tell the nurses that the assignments will be more equitable in the future. D. Ask each nurse to take turns making the assignments.

Correct Answer is B

Explanation

A. Incorrect. Avoiding the issue by scheduling the nurses to have fewer shifts together might not address the underlying conflict and could lead to resentment.

B. Correct. Encouraging collaboration empowers the nurses to work together and find common ground in making assignments.

C. Incorrect. While promising more equitable assignments is important, addressing the conflict directly and encouraging collaboration is a more proactive approach.

D. Incorrect. Asking each nurse to take turns making the assignments might not resolve the perceived favoritism and could create further tension.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A charge nurse is observing a conflict between two nurses who both insist that the charge nurse favors the other when making assignments. Which of the following conflict-resolution strategies should the charge nurse use?

Correct Answer is B

Explanation

A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?

A nurse in an outpatient clinic is caring for a client Vital Signs BP 124/68 mm Hg Heart rate 80/min Temperature 37° C (98.6° F) Respiratory rate 16/min Weight 67.1 kg (148 lb)

A nurse is caring for a client whose partner recently died. The nurse sits with the client to provide comfort. Which of the following ethical principles is the nurse demonstrating?

A nurse is providing teaching about immunizations to a client who is pregnant. Which of the following statements should the nurse include in the teaching?

A nurse is providing teaching about the use of crutches using a three-point gait to a client who has a tibia fracture. Which of the following actions by the client indicates an understanding of the teaching?

A nurse is assessing a client who is taking digoxin to treat chronic heart failure.Which of the following findings should indicate to the nurse that the client is developing digoxin toxicity?

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?

A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position.Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension?