A nurse is caring for a client in the outpatient mental health clinic
History and Physical
2 months ago:
Client states, "My depression has been getting a little worse Lately."
Client reports increased fatigue, sadness, and hypersomnia over the last few months. Client reports their manifestations have
been well-controlled "for years" on fluoxetine, but "it seems to
have stopped working." Client denies any physical complications or suicidal ideation.
Client has history of depression and hyperlipidemia.
Client lives at home with partner and 4-year-old child. Denies alcohol, illicit drug, or tobacco use Exercises occasionally.
Click to highlight the findings that indicate the client is experiencing adverse effects of the medication. To deselect a finding, click on the finding again
Nurses' Notes
Today
Vital Signs
Today
BP 149/91 mm Hg
Heart rate 75min
Respiratory rate 18/min
The Correct Answer is ["A","B"]
Client states "I’m feeling much better." They report less fatigue even though they have difficulty sleeping. Client reports they are not sad anymore but are experiencing more frequent headaches. Client continues to deny any suicidal ideation
Vital Signs
Today
BP 149/91 mm Hg
Heart rate 75min
Respiratory rate 18/min
Explanation:
Based on the provided information, the following findings indicate the client may be experiencing adverse effects of the medication (fluoxetine):
-
Increased headaches: The client reports experiencing more frequent headaches, which can be an adverse effect of fluoxetine.
-
Difficulty sleeping (hypersomnia): The client reports difficulty sleeping despite feeling less fatigued, which could be related to the medication's effect on sleep patterns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. Placing a pillow under the client's knees would not specifically address preventing a compromise in placental blood flow.
B. Correct. Positioning the client in reverse Trendelenburg (head of the bed elevated) helps prevent the weight of the gravid uterus from compressing the inferior vena cava, which can compromise blood flow back to the heart and decrease placental blood flow during a cesarean birth.
C. Incorrect. The lithotomy position is used for vaginal deliveries and involves placing the client's feet in stirrups, which is not appropriate for a cesarean birth.
D. Incorrect. Placing a wedge under one of the client's hips would not address the potential compromise in placental blood flow.
Correct Answer is C
Explanation
A. Incorrect. Documenting the client's understanding of adverse effects is important, but ensuring the client's knowledge about diaphragm use is the first step.
B. Incorrect. Teaching the client how to insert the diaphragm can be an important step, but first, it's essential to assess the client's existing knowledge.
C. Correct. Before proceeding with teaching or other actions, it's important to determine the client's baseline understanding of diaphragm use.
D. Incorrect. Supervising the return demonstration is important but should come after the client's knowledge level is assessed.
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