Exhibits
The nurse receives the prescription for sertraline and prepares to give the medication.
The nurse reviews the current medication prescription. Click to specify if the intervention is indicated or not indicated. Each row must have only one response selected.
Assess for pattern of bowel movements.
Monitor suicidal ideation.
Weigh client weekly.
Offer frequent sips of fluids.
Watch for hypotension.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}
Rationale:
- Assess for pattern of bowel movements: Sertraline, a SSRI, commonly causes gastrointestinal side effects, including diarrhea or constipation. Monitoring the client's bowel movement pattern is essential to detect and manage these potential adverse effects.
- Monitor suicidal ideation: Clients with PTSD and major depressive symptoms, especially those recently expressing suicidal intent, require close monitoring for suicidality when initiating SSRIs like sertraline, as energy to act on suicidal thoughts may increase before mood improves.
- Weigh client weekly: SSRIs, including sertraline, can lead to weight changes. Regular weight monitoring helps detect significant weight gain or loss, especially in clients with changes in appetite or nutrition due to mood disorders.
- Offer frequent sips of fluids: There is no current evidence of dehydration or dry mouth. SSRIs like sertraline do not routinely require fluid intake encouragement unless side effects or clinical symptoms indicate a need.
- Watch for hypotension: Sertraline is not commonly associated with hypotension. Orthostatic hypotension is more typical with tricyclic antidepressants or antipsychotics, not SSRIs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Full volume of pedal pulses: Pedal pulses reflect peripheral arterial circulation, not neuropathic pain. Pregabalin does not affect vascular flow, so this finding is unrelated to the medication’s intended effect.
B. Reduced level of pain: Pregabalin is an anticonvulsant used to treat neuropathic pain by modulating nerve signals. A reduction in reported pain confirms that the medication is helping manage the client’s diabetic nerve pain.
C. Granulating tissue in foot ulcer: Wound healing is influenced by infection control, circulation, and blood glucose management—not directly by pregabalin. While important, this finding does not measure the drug’s effectiveness for neuropathy.
D. Improved visual acuity: Visual changes are not treated with pregabalin and may be associated with diabetic retinopathy. Pregabalin does not improve vision and is not indicated for ocular complications of diabetes.
Correct Answer is A
Explanation
Rationale:
A. "Chest physiotherapy should be performed twice a day before a meal.” Chest physiotherapy helps clear mucus from the lungs and is most effective when done before meals to prevent vomiting and optimize lung function and oxygenation.
B. "Administer a cough suppressant every 8 hours." Cough suppressants are generally avoided in cystic fibrosis because coughing is necessary to mobilize and expel thick secretions from the airways.
C. "Energy should be conserved by scheduling minimally strenuous activities." Physical activity is encouraged to enhance lung expansion and mucus clearance. Energy conservation is not the priority unless the child is acutely ill.
D. "Maintain supplemental oxygen at 4 to 6 L/minute." High-flow oxygen is not routinely used and may suppress respiratory drive. Oxygen is used with caution and only as prescribed in advanced disease or during exacerbations.
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