An 11-year-old client has been hospitalized on the adolescent psychiatry unit with severe depression. For the past several weeks, the client has been prescribed a selective serotonin reuptake inhibitor (SSRI). What is the priority nursing action?

Monitor food intake and eliminate potential sources of tyramine.

Assess for weight loss and difficulty sleeping.

Monitor the client for migraines.

Implement suicide precautions.

Answer and Explanation

The Correct Answer is D

D. Children and adolescents with depression, especially when initiating or adjusting antidepressant medications like SSRIs, are at an increased risk of suicidal ideation and behavior. Therefore, it is crucial to prioritize the safety of the client by implementing suicide precautions, which may include close observation, removing potential means of self-harm, and involving the client in structured activities under supervision.

A. Monitoring food intake and eliminating potential sources of tyramine are considerations for clients taking monoamine oxidase inhibitors (MAOIs), another class of antidepressant medications, due to the risk of hypertensive crisis.

B. Weight loss and difficulty sleeping are potential side effects of SSRIs that may occur, particularly during the initial phases of treatment. However, suicide precautions are a priority

C. While SSRIs may cause headaches or migraines as potential side effects, monitoring for migraines specifically would not typically be a priority

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Correct Answer is ["A","B","C"]

Explanation

A. Tardive dyskinesia can involve abnormal, involuntary movements of the hips, pelvis, and trunk.
B. Facial grimacing and eye blinking are common manifestations of tardive dyskinesia. These movements involve involuntary contractions of facial muscles, leading to facial distortions and repetitive blinking.
C. Tongue thrusting and lip smacking are classic signs of tardive dyskinesia. These movements involve involuntary protrusion of the tongue and repetitive puckering or smacking of the lips.

D. Fine hand tremors and pill rolling movements are more commonly associated with other movement disorders, such as Parkinsonism, which can also be caused by certain antipsychotic medications but are distinct from tardive dyskinesia.
E. Urinary retention and constipation are not typical symptoms of tardive dyskinesia. These symptoms may occur due to other factors, such as anticholinergic effects of medications or medical conditions unrelated to tardive dyskinesia.

A. Check the client's belongings for additional drugs. B. Pad the side rails of the bed because seizures are likely. C. Prepare a dose of ipecac, an emetic. D. Monitor respiratory function.

Correct Answer is D

Explanation

D. Barbiturates can cause respiratory depression, hypoventilation, and potentially respiratory arrest, which can lead to hypoxia and cardiac arrest if not promptly recognized and managed.

A. While it's important to assess for any additional drugs or substances that the client may have ingested, this action is not the priority when managing a client with a barbiturate overdose.

B. Seizures can occur as a result of barbiturate overdose, but respiratory depression is the more immediate and life-threatening concern.

C. Ipecac is no longer recommended for the induction of vomiting in cases of drug overdose due to the risk of complications such as aspiration pneumonia and delayed treatment.

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An 11-year-old client has been hospitalized on the adolescent psychiatry unit with severe depression. For the past several weeks, the client has been prescribed a selective serotonin reuptake inhibitor (SSRI). What is the priority nursing action?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (Select all that apply)

Correct Answer is ["A","B","C"]

Explanation

A client is admitted for a drug overdose with a barbiturate. Which is the priority nursing action when planning care for this client?

Correct Answer is D

Explanation

Which behavior would first alert the school nurse or teacher to suspect sexual abuse in a 7-year- old child?

A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?

A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?

An 11-year-old client has been hospitalized on the adolescent psychiatry unit with severe depression. For the past several weeks, the client has been prescribed a selective serotonin reuptake inhibitor (SSRI). What is the priority nursing action?

The client with schizophrenia believes the student nurses are there to spy on the clients. The client is suffering from which of the following symptoms?

A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply.)