A nurse is caring for a client in the outpatient mental health clinic

exhibits

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

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

difficulty sleeping

frequent headaches

feeling much better

less fatigue

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Incorrect. While it’s important to have support during an examination, having multiple nurses present could be overwhelming for the child and may not be necessary. Instead, it's often best to have a single nurse and possibly a pediatric specialist or social worker present, ensuring the child feels safe and comfortable.
B. Incorrect. Reassuring the child that no one will be told is inappropriate as reporting suspected abuse is required by law.
C. Correct. It helps prepare the child for the next steps in the process and can reduce anxiety. Clear communication fosters trust and helps the child understand the importance of reporting for their safety and well-being.
D. Incorrect. Using leading statements can potentially affect the integrity of the investigation.

A. Remove the client's restraint every 4 hr. B. Attach the restraint to the bed's side rails. C. Request a PRN restraint prescription for clients who are aggressive. D. Document the client's condition every 15 min.

Correct Answer is D

Explanation

A. Incorrect. Restraints should be removed and repositioned, and the client's needs assessed at a frequency that follows institutional policies, which might not always be every 4 hours.

B. Incorrect. Restraints should be attached to the bed frame, not the side rails, to minimize the risk of injury.

C. Incorrect. PRN (as needed) restraint prescriptions should be avoided. Restraints should only be used based on specific criteria and under the guidance of a healthcare provider.

D. Correct. When using restraints, it's important to document the client's condition frequently to assess for any potential adverse effects or discomfort.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a child who reports being sexually abused by a family member. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?

Correct Answer is D

Explanation

A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin?

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