A client who experiences recurrent episodes of depression tells the nurse of a desire to discontinue the prescribed antidepressant. The client describes feeling less depressed after taking the medication for the past couple of weeks and the client does not like the side effects of the medication. Which response is best for the nurse to provide?

Inform the client that gradual tapering must be used to discontinue the medication.

Tell the client that the medication's side effects will most likely dissipate over time.

Remind the client that feeling better is the therapeutic effect of the medication.

Tell the client to discuss the medication side effects with the healthcare provider.

Answer and Explanation

The Correct Answer is A

A. Informing the client that gradual tapering must be used to discontinue the medication is crucial because abruptly stopping antidepressants can lead to withdrawal symptoms or the return of depressive symptoms. This response acknowledges the client’s concerns and provides a safe approach to discontinuation.

B. While side effects may diminish over time for some individuals, this response does not address the client's concerns or provide guidance on how to manage the side effects.
C. Reminding the client that feeling better is the therapeutic effect of the medication does not address the client's concerns about side effects or desire to discontinue the medication.

D. While discussing side effects with the healthcare provider is important, it does not address the need for a safe discontinuation process, which is why gradual tapering should be emphasized first.

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Correct Answer is B

Explanation

A. Swollen feet and ankles: While swelling can indicate fluid retention, it may not necessarily warrant immediate intervention unless it is severe or accompanied by other concerning symptoms.

B. Blood-tinged sputum is the most concerning finding because it suggests pulmonary congestion or pulmonary edema, which can occur due to increased pressure in the pulmonary circulation secondary to mitral valve stenosis. This could indicate acute decompensation of the client’s condition, requiring immediate intervention to prevent respiratory compromise or worsening heart failure.

C. Rapid, regular heart rate (e.g., sinus tachycardia) is a compensatory response to reduced cardiac output and increased demand. While it warrants monitoring and potential treatment, it is not as critical as the presence of blood-tinged sputum, which signals acute pulmonary involvement

D. Elevated blood pressure: While elevated blood pressure may indicate increased cardiac workload, rapid, irregular heart rate is a more immediate concern in this context due to its potential to cause complications such as thromboembolism

A. Remove dentures or other oral appliance. B. Elevate the head of the bed to a 45-degree angle. C. Apply the client's positive airway pressure device. D. Lift and lock the side rails in place.

Correct Answer is C

Explanation

A. Remove dentures or other oral appliance: While important for airway management, it is not specifically related to the client's condition of sleep apnea.
B. Elevate the head of the bed to a 45-degree angle: This intervention can help reduce the risk of aspiration but is not specific to managing sleep apnea.
C. Apply the client's positive airway pressure device: Clients with obstructive sleep apnea often use positive airway pressure devices to maintain airway patency during sleep, so ensuring its application is crucial.
D. Lift and lock the side rails in place: This intervention is important for client safety but does not directly address the client's sleep apnea.

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Naxlex Comprehensive Predictor Exams

A client with a history of rheumatic fever is diagnosed with mitral valve stenosis. The client has shortness of breath with exertion and fatigue. Which assessment finding warrants immediate intervention by the nurse?

Correct Answer is B

Explanation

The nurse places an opioid patch on the chest of a client with intractable pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client?

Correct Answer is C

Explanation

An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

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

A 22-year-old client is admitted to the hospital in diabetic ketoacidosis (DKA. The client's parent is insisting to know the laboratory test results. Which is the best response for the nurse to provide?

Exhibits What should the nurse include in post discharge care education? Select all that apply.

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. What instruction(s) should the nurse include in the client's discharge teaching plan? Select all that apply.

The parent of a child born with a myelomeningocele asks the nurse, "What did I do to deserve this?" Which response is most helpful?

The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

A client with type 1 diabetes mellitus (DM) is admitted in diabetic ketoacidosis. Treatment is initiated, and the nurse is preparing to administer IV fluids containing potassium chloride. Which assessment data is most important for the nurse to obtain before starting the infusion?