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 C

Explanation

A. Incorrect. Placing a towel roll under the client's neck is a preventive measure to maintain proper cervical alignment, but it does not specifically address contracture prevention.

B. Incorrect. This can promote flexion of the knees, which may actually contribute to knee flexion contractures over time. While it might be comfortable for the client, it's not a preventive measure against contractures.

C. Correct. Orthotics can help maintain proper alignment of the foot and ankle, preventing foot drop and other related contractures. They are designed to support joints and muscles, minimizing the risk of stiffness and contracture formation.

D. Incorrect. Aligning a trochanter wedge between the client's legs might help prevent external rotation of the hips but does not specifically address contracture prevention.

A. Continuously monitor the child's respiratory status. B. Administer pancreatic enzymes with meals. C. Assess the child for frequent swallowing. D. Carefully suction the child's oropharynx to remove secretions.

Correct Answer is A

Explanation

A. Correct. Epiglottitis can cause airway obstruction, so continuous respiratory monitoring is crucial to detect any signs of respiratory distress.

B. Incorrect. Administering pancreatic enzymes is not relevant to epiglottitis.

C. Incorrect. Frequent swallowing assessment is not the priority for epiglottitis. Airway management is.

D. Incorrect. Suctioning may be necessary, but continuous respiratory monitoring takes precedence.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture?

Correct Answer is C

Explanation

A nurse is planning care for a toddler who has epiglottitis. Which of the following interventions should the nurse include?

Correct Answer is A

Explanation

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