A nurse is reinforcing teaching with a client who has a history of depression about a new prescription for fluoxetine.
Which statement by the client indicates understanding of the teaching?
“I will increase my water intake up to 8 glasses a day.”
“I may experience sedation and sleepiness.”
“I will notice an improvement in my sex drive.”
“I should expect to feel better within 3 to 4 days.”
The Correct Answer is B
Choice A rationale:
Increased water intake is not a specific teaching point for fluoxetine. While general hydration is important for overall health, it's not directly related to the medication's effectiveness or side effects.
Fluoxetine is not known to cause dehydration or require fluid intake beyond typical recommendations.
Focusing on water intake could potentially distract from more relevant education about the medication.
Choice B rationale:
Sedation and sleepiness are common side effects of fluoxetine, especially during the initial weeks of treatment.
It's important for the client to be aware of these potential side effects so they can make necessary adjustments to their activities, such as avoiding driving or operating machinery if drowsy.
Understanding that these side effects are expected can also help with adherence to treatment, as clients may be less likely to discontinue the medication if they know that the side effects are likely to subside over time.
Choice C rationale:
Fluoxetine can sometimes cause sexual side effects, such as decreased libido or difficulty achieving orgasm.
It's important for the client to be aware of this potential side effect, but it's not accurate to say that they will definitely notice an improvement in their sex drive.
Sexual side effects can be distressing and may impact treatment adherence, so open communication with the healthcare provider is essential if these issues arise.
Choice D rationale:
Fluoxetine can take several weeks, typically 4-6 weeks, to fully exert its therapeutic effects.
Expecting to feel better within 3-4 days could lead to disappointment and frustration if symptom improvement isn't immediately noticeable.
It's important for the client to understand that patience is needed while the medication takes effect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
- Answer and explanation The correct answers are:
Condition:
- Mania Actions:
- Daily weight
D. Suicidal behavior
Parameters to monitor:
Blood pressure and pulse rate
Food intake during meals
Rationale for condition:
Choice A: Mania
The client's presentation is consistent with the manic phase of bipolar disorder.
Key features of mania include:
Elevated mood or irritability
Increased energy and activity levels
Racing thoughts and rapid speech
Decreased need for sleep Impulsive behavior
Distractibility
Poor judgment
Grandiosity
Auditory hallucinations Rationale for actions:
Choice B: Daily weight
Weight loss is a common symptom of mania due to increased activity levels and decreased appetite.
Monitoring weight helps assess the severity of mania and the need for nutritional interventions.
Choice D: Suicidal behavior
Individuals with bipolar disorder are at increased risk for suicide, especially during manic episodes.
Close monitoring for suicidal ideation and behavior is crucial for safety.
Rationale for parameters to monitor:
Choice A: Blood pressure and pulse rate
Mania can lead to physiological changes such as increased heart rate and blood pressure.
Monitoring these vital signs helps assess the physical impact of mania and the potential need for medical interventions.
Choice C: Food intake during meals
As mentioned, decreased appetite is common in mania.
Monitoring food intake ensures adequate nutrition and prevents dehydration.
Correct Answer is C
Explanation
The correct answer is choicec. The client paces in the hallway during the day and most of the night.
Choice A rationale:Giving away personal items and money can indicate impulsivity and poor judgment, which are common in manic episodes. However, this behavior does not pose an immediate physical risk to the client or others.
Choice B rationale:Hostility and sarcasm towards staff can indicate irritability and agitation, which are also common in mania. While this behavior can disrupt the therapeutic environment, it is not the highest priority unless it escalates to physical aggression.
Choice C rationale:Pacing in the hallway during the day and most of the night indicates severe hyperactivity and potential exhaustion. This behavior poses a significant risk to the client’s physical health due to the possibility of dehydration, exhaustion, and other complications from lack of rest.
Choice D rationale:Demonstrating flight of ideas is a cognitive symptom of mania where the client rapidly shifts from one idea to another. While this can affect communication and thought processes, it does not pose an immediate physical risk.
In summary, the priority is to address behaviors that pose the greatest immediate risk to the client’s physical health and safety.
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