A nurse is caring for a client in the outpatient health clinic.
For each potential nursing intervention, click to specify if the intervention is indicated or not indicated.
Instruct client to avoid foods that have been fermented or aged.
Encourage client to sleep until later in the morning.
Advise client to notify provider if pregnant.
Encourage high-calorie finger foods.
Advise client to rise slowly from sitting position.
Encourage naps during the day when client is tired.
Encourage a regular sleep-wake schedule.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"}}
Rationale:
- Instruct client to avoid foods that have been fermented or aged: This dietary restriction applies to monoamine oxidase inhibitors (MAOIs), not trazodone, which is a serotonin antagonist and reuptake inhibitor (SARI).
- Encourage client to sleep until later in the morning: Oversleeping can disrupt circadian rhythms and worsen fatigue. A consistent, balanced sleep schedule is more therapeutic.
- Advise client to notify provider if pregnant: Trazodone is a category C medication and should only be used in pregnancy if the benefits outweigh the risks. The provider must be informed if the client is or may become pregnant.
- Encourage high-calorie finger foods: The client has experienced weight loss and decreased appetite. Nutrient-dense, easy-to-eat foods can support caloric intake without requiring full meals.
- Advise client to rise slowly from sitting position: Trazodone can cause orthostatic hypotension. Educating the client to change positions slowly helps prevent dizziness and potential falls.
- Encourage naps during the day when client is tired: Daytime napping can interfere with nighttime sleep and may reduce trazodone’s effectiveness in establishing a healthy sleep pattern.
- Encourage a regular sleep-wake schedule: Trazodone is often prescribed for sleep difficulties. A consistent routine supports sleep hygiene and enhances the medication’s effectiveness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Bradycardia: Ectopic pregnancy is more likely to cause tachycardia due to internal bleeding and hypovolemia from tubal rupture. Bradycardia is not a typical finding and would suggest a different or more advanced issue.
B. Hypertension: Hypotension, not hypertension, may occur in cases of significant bleeding from a ruptured ectopic pregnancy. Elevated blood pressure is not a hallmark sign of this condition.
C. Hydramnios: Hydramnios refers to excessive amniotic fluid and is associated with fetal anomalies or maternal diabetes. It is unrelated to ectopic pregnancy, where implantation occurs outside the uterine cavity.
D. Abdominal pain: Sharp or stabbing abdominal or pelvic pain is a classic symptom of ectopic pregnancy. It may be accompanied by vaginal bleeding and referred shoulder pain if internal bleeding irritates the diaphragm.
Correct Answer is A
Explanation
Rationale:
A. Sore throat: A sore throat may indicate agranulocytosis, a serious adverse effect of clozapine that results in dangerously low white blood cell counts. Early signs include fever, sore throat, and malaise. This requires immediate reporting and evaluation with a complete blood count.
B. Tinnitus: Tinnitus is not a known or common adverse effect of clozapine. While bothersome, it is not typically associated with the hematologic or metabolic risks posed by this antipsychotic medication.
C. Rhinitis: Although rhinitis can occur with many medications, it is not a serious or expected side effect of clozapine requiring urgent attention. Mild nasal symptoms are usually self-limiting and not indicative of life-threatening complications.
D. Headache: Headaches are common and nonspecific symptoms that may result from various causes. Unless severe or persistent, they do not typically indicate a dangerous reaction to clozapine and are not prioritized over signs of infection.
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