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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Akathisia: Akathisia is characterized by restlessness and an inability to sit still. While it can be a side effect of antipsychotic medications like haloperidol, it does not present with fever, hypertension, and muscle rigidity, as described in the scenario.
B. Neuroleptic malignant syndrome (NMS): NMS is a potentially life-threatening condition associated with antipsychotic medications like haloperidol. It is characterized by hyperthermia, autonomic dysfunction (e.g., hypertension), altered mental status, and severe muscle rigidity. The client's symptoms of fever, elevated blood pressure, and muscle rigidity are consistent with NMS.
C. Tardive dyskinesia: Tardive dyskinesia is a movement disorder characterized by involuntary, repetitive movements of the face, tongue, and other body parts. It is a long-term side effect of antipsychotic medications and typically develops after prolonged use, unlike the acute onset seen in the scenario.
D. Agranulocytosis: Agranulocytosis is a rare but serious side effect of antipsychotic medications, characterized by a severe reduction in white blood cell count, leading to an increased risk of infection. The symptoms described in the scenario are not consistent with agranulocytosis.
Correct Answer is A
Explanation
A. Documents medication administration prior to administering it: Documenting medication administration before actually administering it is incorrect and can lead to errors in documentation. The nurse should document medication administration after ensuring the medication is given to the client.
B. Verifies the medication against the prescription and medication label: This is a correct action. The nurse should verify the medication against the prescription and medication label to ensure accuracy before administering it.
C. Checks the provider's orders and confirmed dosage in a medication reference guide: This is a correct action. The nurse should check the provider's orders and confirm the dosage in a reliable medication reference guide to ensure accuracy before administering the medication.
D. Scans the barcode on the medication administration record and the client's armband: This is a correct action. Scanning the barcode on the medication administration record and the client's armband helps ensure the "Five Rights" of medication administration: right patient, right medication, right dose, right route, and right time.
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