A nurse is caring for a client in a clinic.
For each body system below, click to specify the adverse effect that the nurse should include in the teaching. Choose the most likely response for the dropdown(s) in the table below by choosing from the lists of options.
|
Body System |
Common Adverse Effects |
|
Head, eyes, ears, nose, and throat (HEENT) |
_____
|
|
Cardiovascular |
_____
|
|
Genitourinary |
_____
|
|
Gastrointestinal |
_____
|
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C","dropdown-group-3":"B","dropdown-group-4":"A"}
Rationale:
• HEENT – Dry mouth: SSRIs such as sertraline commonly cause dry mouth due to anticholinergic effects and altered salivary secretion. Clients may notice difficulty swallowing, increased thirst, or altered taste. Education should include strategies to manage dry mouth, such as frequent sips of water, sugar-free gum, or saliva substitutes.
• Cardiovascular – Tachycardia: Sertraline may increase sympathetic nervous system activity, leading to mild tachycardia. Clients should monitor heart rate and report palpitations, lightheadedness, or other cardiovascular changes. Although usually mild, monitoring is important for those with underlying heart conditions.
• Genitourinary – Urinary retention: SSRIs can interfere with detrusor muscle function and bladder emptying, leading to urinary retention in some clients. Teaching includes observing for difficulty urinating, straining, or reduced urine output, and reporting persistent problems to the provider.
• Gastrointestinal – Diarrhea: Gastrointestinal upset is common when starting SSRIs, including diarrhea, nausea, and abdominal cramping. This occurs due to increased serotonin in the gut. Patients should be advised to maintain hydration and report severe or persistent symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
A. Wear a gown when providing care: Contact precautions are required for clients with Clostridium difficile infection. Wearing a gown prevents contamination of the nurse’s clothing with infectious spores, reducing the risk of transmission to other clients or surfaces.
B. Change gloves after contact with infectious material: Gloves must be changed after any contact with infectious material, such as feces or contaminated surfaces, to prevent cross-contamination and protect the nurse and other clients from exposure.
C. Remove the thermometer from client's room for use on another client: Medical equipment must remain in the client’s room or be thoroughly disinfected before reuse. Removing thermometers without proper disinfection risks spreading C. difficile spores to other clients.
D. Wear an N95 respirator when providing care: N95 respirators are indicated for airborne precautions, not contact precautions. C. difficile is transmitted via the fecal-oral route and does not require respiratory protection unless aerosol-generating procedures occur.
E. Wash hands with an alcohol-based cleaner: Alcohol-based hand sanitizers are ineffective against C. difficile spores. Handwashing with soap and water is required to physically remove spores and prevent transmission.
Correct Answer is C
Explanation
A. Have the client store smaller tanks under his bed: Storing oxygen tanks under the bed poses a serious fire hazard and increases the risk of accidental tipping or damage. Proper storage requires a stable, upright position in a well-ventilated area away from flammable materials.
B. Ensure that the client checks the gauge weekly: Oxygen tanks should be checked daily to ensure adequate supply and to prevent sudden depletion. Waiting a week between checks could result in unexpected oxygen interruption, which is unsafe for clients dependent on supplemental oxygen.
C. Place the oxygen tank away from curtains or drapes: Oxygen supports combustion, and placing tanks near flammable materials such as curtains, drapes, or open flames increases the risk of fire. Proper placement in a clear, ventilated area is a critical safety measure for home oxygen therapy.
D. Store the oxygen tank wrench in a locked cabinet: While securing equipment is generally safe, the oxygen tank wrench must be readily accessible in case of emergency or the need to quickly turn off the oxygen. Locking it away could delay urgent intervention.
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