Patient Data

The client has been diagnosed with depression by the healthcare provider (HCP). Prescriptions are received for discharge. Choose the most likely options for the information missing from the statements by selecting from the lists of options provided.

The nurse instructs the client that sertraline can cause
_
and that the client can manage this side effect with
__

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Rationale for correct choices:
• Dry mouth: Sertraline, a selective serotonin reuptake inhibitor (SSRI), commonly causes mild anticholinergic side effects such as dry mouth. This occurs due to decreased salivary secretion and is a frequent, non-serious adverse effect seen in clients taking antidepressants.

• Sips of water: Taking frequent sips of water is an appropriate and effective way to relieve dry mouth. It helps maintain oral moisture and comfort without causing harm or interfering with medication therapy.

Rationale for incorrect choices:
• Hypernatremia: SSRIs like sertraline are more commonly associated with hyponatremia (low sodium), especially in older adults, not hypernatremia. Therefore, this is incorrect.

• Elevated blood pressure: Sertraline does not typically cause hypertension. Some antidepressants (like SNRIs) may increase blood pressure, but SSRIs generally do not.

• Frequent rest: This intervention is more appropriate for managing fatigue, not dry mouth.

• Elevation of legs: This is used for edema or circulation issues and has no role in managing dry mouth.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Mild fever after the Hib vaccine is a normal immune response and usually not dangerous. Parents should monitor for high or persistent fevers above 102°F or other concerning symptoms such as lethargy, persistent vomiting, seizure, or difficulty breathing. Routine mild fevers do not require immediate medical attention, so reporting every small fever is unnecessary and can cause anxiety.

B. Children can return to daycare or normal activities immediately after vaccination if they are otherwise well. Mild local reactions or fever do not prevent attendance. Keeping a child home unnecessarily does not improve safety or outcomes.

C. Aspirin is contraindicated in children due to the risk of Reye’s syndrome, a rare but potentially fatal condition affecting the liver and brain. For post-vaccine discomfort, acetaminophen or ibuprofen is safe when given in the correct pediatric dose.

D. Applying a cool pack to the injection site is a safe, effective way to reduce local pain, redness, or swelling. Parents should apply a cool, clean cloth or ice pack for 10–15 minutes at a time and watch for unusual reactions such as excessive swelling, warmth, or pus, which would require contacting the provider. This method is noninvasive, evidence-based, and appropriate for post-vaccine care.

A. Atopic dermatitis. B. Lentigines. C. Tinea capitis. D. Impetigo.

Correct Answer is B

Explanation

A. Atopic dermatitis is a chronic inflammatory skin condition that typically begins in childhood and may persist into adulthood. While older adults can have eczema, it is not an expected finding due to normal aging and is less common in this population, especially in someone without a prior history.

B. Lentigines, also called age spots or liver spots, are flat, brown macules that develop on sun-exposed areas of the skin, such as the face, hands, and forearms. Older adults with a history of extensive sun exposure, such as a retired farmer, are particularly prone to developing lentigines due to cumulative ultraviolet (UV) damage over the years. These lesions are benign and a normal finding in aging skin.

C. Tinea capitis is a fungal infection of the scalp most commonly seen in children. It is rare in older adults, and its presence would be considered abnormal rather than an expected age-related change.

D. Impetigo is a superficial bacterial skin infection, most frequently seen in young children or in individuals with poor hygiene or immunocompromise. It is not an expected lesion in healthy older adults and would indicate an acute pathological process rather than a normal aging change.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A parent asked the nurse how to care for their 4-year-old child after receiving the Haemophilus influenzae type b (Hib) conjugate vaccine. Which instruction should the nurse provide?

Correct Answer is D

Explanation

The nurse is conducting an assessment on an older adult retired farmer. Which skin lesion should the nurse expect to see?

Correct Answer is B

Explanation

While the nurse is conducting an admission assessment of a female client with bipolar disorder, the client suddenly begins to take off her clothes and throw them about the room. Which action should the nurse take first?

Fifteen minutes after receiving sulfamethoxazole-trimethoprim (SMZ-TMP), the client reports a burning sensation over the abdomen, chest, and groin. Which intervention is most important for the nurse to implement?

A client with a history of a bilateral adrenalectomy is admitted with a weak, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse?

Patient Data The client returns to the clinic for his four week follow up appointment. Which 3 statements made by the client indicate his depression is improving?

A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several side effects since taking the drug. Which side effect should the nurse report to the healthcare provider?

The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client's room after taking vital signs. Which action should the nurse take?

The nurse is caring for a client with the sexually transmitted infection (STI) human papillomavirus (HPV). The client reports having had prior sexually transmitted infections. Which response should the nurse provide?

The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? Select all that apply.