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 D
Explanation
A. Incorrect. Clamping the catheter tubing might not be necessary in this situation and could potentially cause urinary retention.
B. Incorrect. While obtaining a urine specimen might be necessary if there's suspicion of infection, the immediate concern in this case is the low urine output rather than infection. Therefore, this may not be the first action taken.
C. Incorrect. Continuous bladder irrigation might be indicated for specific situations, such as after certain surgeries, but it is not the first-line intervention based solely on the description provided.
D. Incorrect. Administering a fluid bolus might not be necessary unless there are other signs of dehydration or fluid imbalance.
Correct Answer is B
Explanation
Among the given assessment findings, the one that warrants the most immediate intervention by the nurse is the shortness of breath on exertion. Shortness of breath on exertion in a client with a history of chronic obstructive pulmonary disease (COPD) and pneumonia indicates increased respiratory distress and compromised lung function. It suggests that the client is experiencing difficulty breathing even with minimal physical exertion. This finding may indicate worsening respiratory status, increased oxygen demand, and inadequate oxygenation. The nurse should take immediate action to address the shortness of breath, which may involve providing supplemental oxygen, initiating or adjusting bronchodilator medications, and monitoring the client's respiratory status closely. Prompt intervention is crucial to ensure adequate oxygenation and prevent respiratory failure.
While the other assessment findings (bilateral diffuse wheezing, temperature of 100.5 °F, and yellow expectorated sputum) are also important and require attention, the shortness of breath on exertion poses the greatest immediate risk and necessitates immediate intervention to address the client's respiratory distress.
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