A nurse is caring for a client who is recovering from a cerebrovascular accident in a rehabilitation facility. The client tells the nurse, "I am sick of being in here, and I want to go home." Which of the following responses should the nurse make?

"You are making progress in your treatment plan."

"You should call your partner to discuss this."

"It must be very frustrating for you to be here."

"It would be best to discuss your feelings with your provider."

Answer and Explanation

The Correct Answer is C

A. "You are making progress in your treatment plan." While this response provides positive reinforcement, it doesn't address the client's feelings of frustration or desire to go home, potentially invalidating their emotions.

B. "You should call your partner to discuss this." Suggesting that the client call their partner shifts the focus away from their feelings and may not provide the immediate emotional support they need.

C. "It must be very frustrating for you to be here." This response acknowledges the client's feelings and validates their frustration. It opens the door for further discussion about their emotions, helping the client feel heard and understood.

D. "It would be best to discuss your feelings with your provider." This response may dismiss the client's current feelings by directing them away from the nurse, who is present and capable of providing support. It is important to validate the client's feelings first.

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Correct Answer is C

Explanation

A. Metallic taste in mouth: This is not a commonly reported adverse effect of sertraline. While some medications may cause changes in taste, it is not characteristic of SSRIs like sertraline.

B. Increased urinary frequency: This is not a typical adverse effect associated with sertraline. While changes in urinary patterns can occur with some medications, it is not specifically noted for sertraline.

C. Excessive sweating: This is a recognized adverse effect of sertraline and other SSRIs. Patients may experience increased sweating, which can be uncomfortable and distressing.

D. Dry cough: This is not a common side effect of sertraline. While some medications may lead to respiratory side effects, it is not typical for SSRIs like sertraline to cause a dry cough.

A. Fasting blood glucose 100 mg/dL B. Hgb 14 g/dL C. Heart rate 58/min D. WBC count 2,900/mm3

Correct Answer is D

Explanation

A. Fasting blood glucose 100 mg/dL: This level is within the normal range and does not contraindicate the use of clozapine. Monitoring blood glucose is important due to the risk of metabolic syndrome, but a normal level is not a concern.

B. Hgb 14 g/dL: Hemoglobin levels in this range are normal and indicate adequate oxygen-carrying capacity. This finding does not contraindicate the use of clozapine.

C. Heart rate 58/min: A heart rate of 58 beats per minute is considered bradycardic but does not directly contraindicate the use of clozapine. Monitoring cardiovascular health is important, but this alone is not a reason to withhold the medication.

D. WBC count 2,900/mm³: This finding is significant because clozapine can cause agranulocytosis, a potentially life-threatening decrease in white blood cells. A WBC count below 3,000/mm³ is a contraindication for clozapine administration, as it increases the risk of infection and other complications. Therefore, this finding indicates that clozapine should not be administered.

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A nurse is caring for a client who is recovering from a cerebrovascular accident in a rehabilitation facility. The client tells the nurse, "I am sick of being in here, and I want to go home." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include?

Correct Answer is C

Explanation

A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine?

Correct Answer is D

Explanation

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