The nurse assesses that medication teaching about tricyclic antidepressants was understood when the client states:

"They may cause hypomania or recent memory impairment."

"Their full therapeutic potential may not be reached until 4 weeks."

"They should not be given with antianxiety agents."

"Strong or aged cheese should not be eaten while taking them."

Answer and Explanation

The Correct Answer is B

B. Tricyclic antidepressants (TCAs) are known to take some time before their full therapeutic effects are realized, which can indeed be up to four weeks. This delay is due to the gradual changes they induce in the brain's biochemistry.
A. TCAs can cause a variety of side effects but hypomania and recent memory impairment are not typically associated with these medications.
C. TCAs do not have a known interaction with antianxiety agents that would prohibit their concurrent use.
D. The restriction on eating strong or aged cheese is associated with another class of antidepressants known as monoamine oxidase inhibitors (MAOIs), not TCAs.

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Correct Answer is D

Explanation

D. Suicide precautions involve implementing safety measures and close monitoring to prevent the client from engaging in self-harm or suicide attempts. This may include continuous observation, removal of

potentially harmful objects or substances from the client's environment, and close supervision by staff members trained in suicide prevention.
A. Assessing for past suicide attempts can provide valuable information about the severity of the client's suicidal ideation, their previous experiences with suicidal behavior, and any patterns or triggers associated with suicidal crises. However, it is not a priority.
B. Assessing for a specific suicide plan allows the treatment team to evaluate the level of risk and urgency of intervention required to keep the client safe. However, with or without a plan, safety should be prioritized.
C. identifying coping mechanisms is important for overall mental health and well-being. However, it is not the priority intervention when a client reports current suicidal ideation.

A. advise the client to take an anxiolytic to decrease their anxiety level. B. restrain the client to prevent self-harm. C. assist the client to identify the trigger situation and choose a coping strategy. D. encourage the client use self-harm behaviors to release emotion.

Correct Answer is C

Explanation

C. Individuals with borderline personality disorder often struggle with intense emotions and may engage in self-harming behaviors as a maladaptive coping mechanism. Helping the client identify triggers for their distress and teaching them alternative coping strategies, such as mindfulness, grounding techniques, or distress tolerance skills, can empower them to manage their emotions in healthier ways.
A. Anxiolytic medications can help alleviate anxiety symptoms but they are not typically the first-line intervention for addressing acute distress in individuals with borderline personality disorder (BPD).
B. Restraint should not be the first response to a client expressing distress or suicidal ideation. Physical restraint should only be used as a last resort in situations where there is an imminent risk of harm to the client or others and should be implemented by trained professionals following established protocols.
D. Encouraging self-harm behaviors reinforces maladaptive coping strategies and can increase the risk of harm to the client. It is essential to provide support and interventions aimed at reducing self-harming behaviors.

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The nurse assesses that medication teaching about tricyclic antidepressants was understood when the client states:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client notifies a treatment team member of current suicidal ideation. Which nursing intervention would take priority?

Correct Answer is D

Explanation

A client with borderline personality disorder reported to the nurse in the clinic that they feel empty and anxious and wants to cut their arms. The nurse should:

Correct Answer is C

Explanation

The rationale for the nurse needing to be aware of their own feelings while working with the family experiencing domestic violence is best explained as:

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A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. When teaching the client about the effects of tyramine, which foods will the nurse caution the client to avoid?

When assessing a 2-year-old child with suspected autism spectrum disorder, the nurse should be particularly alert for:

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The nurse is educating clients about recovery from alcohol abuse. Which statement indicates that learning has occurred?

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