A nurse is reviewing a pamphlet about sertraline with a client who has post-traumatic stress disorder. Which of the following client statements indicates understanding of the information?

"This medication can cause a dry cough."

"I should call the provider if I experience excessive sweating and muscle twitching."

"This medication can cause harmless, temporary changes to my ability to taste and smell."

“I need to decrease my sodium intake while on this medication."

Answer and Explanation

The Correct Answer is B

A. "This medication can cause a dry cough.": A dry cough is not a common side effect of sertraline.

B. "I should call the provider if I experience excessive sweating and muscle twitching." Excessive sweating and muscle twitching could indicate serotonin syndrome, a potentially life-threatening condition associated with SSRIs like sertraline. Early recognition and prompt intervention are crucial.

C. "This medication can cause harmless, temporary changes to my ability to taste and smell.":
Changes in taste or smell are not typical side effects of sertraline. This statement is incorrect and does not reflect the drug's known side effect profile.

D. "I need to decrease my sodium intake while on this medication.": Sodium intake is not typically affected by sertraline use. However, sertraline can cause hyponatremia in some cases, especially in older adults.

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Correct Answer is B

Explanation

A. Triggering: This phase involves initial stressors or triggers leading to aggression but lacks the intense behavioral and physical symptoms described.

B. Escalation: The escalation phase is characterized by increasing tension, verbal aggression, and physical manifestations like pacing or clenched fists. The client’s behavior suggests they are moving toward a potential crisis.

C. Anger: Anger is an emotion, not a phase of the aggression cycle. It may be present during multiple phases.

D. Crisis: The crisis phase involves loss of control and actual aggressive or violent actions, which has not occurred yet in this scenario.

A. Assess for risk of immediate harm to patient or children B. Implement the safety plan C. Refer the client to a community support group. D. Instruct the client on how to leave the relationship.

Correct Answer is A

Explanation

A. Assess for risk of immediate harm to patient or children: The priority is to ensure the immediate safety of the client and any children involved. If there is a risk of harm, emergency services or protective measures must be initiated.

B. Implement the safety plan: Implementing the safety plan is important but secondary to assessing the immediate risk. Without first understanding the level of danger, the safety plan might not address urgent needs.

C. Refer the client to a community support group: This is a valuable intervention for long-term support but is not the priority in an acute situation where immediate risk must be assessed.

D. Instruct the client on how to leave the relationship: While planning for leaving the relationship is critical, it is not the immediate priority, especially if the client or children are in danger.

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A nurse is reviewing a pamphlet about sertraline with a client who has post-traumatic stress disorder. Which of the following client statements indicates understanding of the information?

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Naxlex Comprehensive Predictor Exams

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