A nurse is admitting a patient exhibiting manic behavior.
The patient reports recent personal stressors, including the loss of her mother and a divorce. What should be the nurse’s priority action?

Encourage self-care.

Assist the patient in identifying coping behaviors.

Prevent self-directed violence.

Identify support systems.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Encouraging self-care is important, but it may not be the immediate priority if the patient is exhibiting manic behavior and has recently experienced significant personal stressors.

Choice B rationale

Assisting the patient in identifying coping behaviors is a key part of treatment, but it may not be the immediate priority if the patient is at risk of self-harm.

Choice C rationale

Preventing self-directed violence is the priority action. Patients exhibiting manic behavior may have impaired judgment and impulse control, putting them at risk of self-harm.

Choice D rationale

Identifying support systems is important, but it may not be the immediate priority if the patient is at risk of self-harm.

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Correct Answer is B

Explanation

Choice A rationale

While swelling in the legs can be a side effect of some medications, it is not a measure of the effectiveness of sertraline. Sertraline is an antidepressant, and its effectiveness would be measured by improvements in mood and behavior.

Choice B rationale

An improvement in mood is a key indicator that the sertraline is effective. Sertraline is a selective serotonin reuptake inhibitor (SSRI) used to treat depression and other mood disorders. It works by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance.

Choice C rationale

While it’s important to monitor blood pressure in patients taking any medication, a blood pressure within the expected range is not specifically an indication of the effectiveness of sertraline.

Choice D rationale

Weight loss is not a primary indicator of the effectiveness of sertraline. While some patients may experience weight changes while taking this medication, it is not a measure of its effectiveness in treating depression or other mood disorders.

A. Provide a list of the client’s current medications during the change of shift report. B. Do not include over-the-counter medications in the medication reconciliation report. C. Do not perform reconciliation for a client at discharge from a health care facility. D. Provide a list of the client’s current medications during admission to a health care facility.

Correct Answer is D

Explanation

Choice A rationale

Providing a list of the client’s current medications during the change of shift report is not a part of medication reconciliation. While it is important to communicate about a patient’s medications during shift changes, medication reconciliation is a more comprehensive process that involves comparing the medications a patient is taking with newly ordered medications.

Choice B rationale

Over-the-counter medications should be included in the medication reconciliation report. Over-the-counter medications can interact with prescription medications and affect a patient’s health, so it’s important to include them in medication reconciliation.

Choice C rationale

Medication reconciliation should be performed for a client at discharge from a health care facility. This is a critical step in ensuring the patient continues to take the correct medications at home.

Choice D rationale

Providing a list of the client’s current medications during admission to a health care facility is a part of medication reconciliation. This helps to ensure that the patient’s medications are correctly managed during their stay in the facility.

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A nurse is admitting a patient exhibiting manic behavior.The patient reports recent personal stressors, including the loss of her mother and a divorce. What should be the nurse’s priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a patient who has been taking sertraline for 2 weeks.Which finding should the nurse identify as an indication that the medication is effective?

Correct Answer is B

Explanation

A nurse is conducting a class on medication reconciliation. What information should the nurse include in the teaching?

Correct Answer is D

Explanation

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A nurse is admitting a patient exhibiting manic behavior.
The patient reports recent personal stressors, including the loss of her mother and a divorce. What should be the nurse’s priority action?