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.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Cyanosis, a bluish discoloration of the skin, may be more visible in areas where the skin is thinner. The sacrum is not reliable especially in the dark colored individuals.
B. Palms of the hand is reliable site for assessing for cyanosis.
C. Incorrect. Shoulders are not a common location to assess for cyanosis. Areas with thinner skin, such as the lips, oral mucosa, and nail beds, are usually observed for cyanosis.
D. Incorrect. Areas of trauma are not specifically used to assess for cyanosis. Cyanosis is a clinical sign that indicates inadequate oxygenation of the blood.

A. Hypotension B. Weight loss C. Polyuria D. Hematuria

Correct Answer is D

Explanation

A. Incorrect. Acute glomerulonephritis can cause fluid retention and hypertension, rather than hypotension.

B. Incorrect. Weight gain might occur due to fluid retention rather than weight loss.

C. Incorrect. Decreased urine output, not polyuria, is a common finding in acute glomerulonephritis.

D. Correct. Hematuria (blood in the urine) is a classic sign of acute glomerulonephritis, reflecting inflammation and damage to the glomeruli in the kidneys.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the client's body should the nurse observe to assess for cyanosis?

Correct Answer is B

Explanation

A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is assessing a 24-month-old toddler at a well-child checkup.Which of the following findings indicates to the nurse that the toddler has developmental delay?

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