A nurse is assessing a client who has been taking sertraline for 2 weeks. The nurse should identify which of the following findings as an indication that the medication is effective?

The client's blood pressure is within the expected reference range.

The client's legs are not swollen.

The client reports a recent weight loss

The client reports increase in mood.

Answer and Explanation

The Correct Answer is D

A. The client's blood pressure is within the expected reference range - While blood pressure monitoring is important during treatment with certain medications, such as antihypertensives, it is not a direct indicator of the effectiveness of sertraline, which is an antidepressant medication.

B. The client's legs are not swollen - Swelling of the legs may be a sign of fluid retention, which can occur with various conditions and medications. However, it is not a specific indicator of the effectiveness of sertraline.

C. The client reports a recent weight loss - Weight changes, including weight loss or gain, can occur as side effects of sertraline. However, weight changes alone do not necessarily indicate the effectiveness of the medication in treating depression.

D. The client reports an increase in mood - Improvement in mood, reduction in depressive symptoms, and overall sense of well-being are primary indicators of the effectiveness of sertraline and other antidepressant medications in treating depression. Therefore, the client reporting an increase in mood suggests that the medication may be effective in managing their symptoms.

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Correct Answer is D

Explanation

A. Hold the injection if seizure activity is present:

This is incorrect. Phenytoin is an antiepileptic medication used to prevent seizures. If a client with a seizure disorder is experiencing seizure activity, it is essential to administer phenytoin promptly to help control and prevent further seizures.

B. Administer the medication at 100 mg/min:

This is incorrect. Phenytoin should be administered at a rate no faster than 50 mg/min to reduce the risk of adverse effects such as hypotension, arrhythmias, and cardiovascular collapse. Rapid infusion can cause adverse reactions such as hypotension, bradycardia, and cardiac arrhythmias.

C. Dilute the medication with dextrose 5% in water:

This is incorrect. Phenytoin should not be diluted with dextrose-containing solutions, as it can cause precipitation and result in clogging of the IV line. It is typically administered undiluted or diluted with normal saline solution.

D. Administer a saline solution after injection:

This is the correct action. After administering phenytoin IV, it is recommended to flush the IV line with normal saline solution to ensure that the medication is fully delivered and to prevent any remaining medication from precipitating in the IV line, which could lead to occlusion.

A. Brain natriuretic peptide B. Erythrocyte sedimentation rate C. Thyroid hormone assay D. Liver function tests

Correct Answer is C

Explanation

A. Brain natriuretic peptide - Brain natriuretic peptide (BNP) is primarily used to diagnose heart failure and assess its severity. It is not routinely monitored in clients taking lithium.

B. Erythrocyte sedimentation rate - Erythrocyte sedimentation rate (ESR) is a nonspecific marker of inflammation and is not specifically related to lithium therapy monitoring.

C. Thyroid hormone assay - Monitoring thyroid function is essential in clients taking lithium because lithium can affect thyroid function, leading to hypothyroidism or hyperthyroidism. Therefore, checking thyroid hormone levels (T3, T4, and TSH) is important before administering lithium.

D. Liver function tests - While lithium can affect liver function in some cases, routine monitoring of liver function tests is not typically required for clients taking lithium. However, periodic liver function tests may be ordered if clinically indicated or if the client has underlying liver disease.

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A nurse is assessing a client who has been taking sertraline for 2 weeks. The nurse should identify which of the following findings as an indication that the medication is effective?

Nursing Test Bank

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