A patient with a history of bipolar I disorder is prescribed fluoxetine (Prozac) for a depressive episode. What is the nurse's priority action?
Assess the patient for gastrointestinal side effects.
Monitor the patient closely for signs of mania.
Administer the medication as ordered
Educate the patient about potential weight gain
The Correct Answer is B
A. While gastrointestinal side effects are common with fluoxetine, they are not the priority concern in the context of bipolar disorder.
B. Fluoxetine (Prozac) is an SSRI used to treat depression, but in patients with bipolar disorder, it can trigger a manic episode. Therefore, the nurse's priority is to monitor for signs of mania, such as increased energy, euphoria, or impulsivity.
C. Administering the medication as ordered is essential, but the nurse must be vigilant for signs of mania, especially with SSRIs in bipolar patients.
D. Educating about weight gain is important but does not address the immediate risk of precipitating mania with fluoxetine in a bipolar patient.
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Related Questions
Correct Answer is D
Explanation
A. Isolating the client is not helpful and may increase anxiety, potentially worsening the compulsive behaviors.
B. Setting strict limits can lead to resistance and increased anxiety, making compulsive behaviors more difficult to manage.
C. Confronting the client about the senseless nature of their compulsions is not effective and may increase anxiety, making the behaviors more intense. Instead, it is important to provide support and understanding while working with the client to reduce the impact of OCD on daily functioning.
D. Clients with OCD often perform compulsive rituals to reduce anxiety. Planning time for rituals allows the nurse to balance the need to manage the behavior with the need to provide structure and care.
Correct Answer is C
Explanation
A. Reality testing refers to the ability to distinguish between what is real and what is not. The client’s belief is a symptom of grandiosity, not a lack of reality testing.
B. Derealization refers to the sense that the external world is unreal or distorted, which is not the case here.
C. Grandiosity is an inflated sense of self-importance and unrealistic beliefs in one’s abilities, as demonstrated by the client’s statement about being able to fly and become a U.S. Senator.
D. Flight of ideas involves rapid, continuous speech with fragmented thoughts that jump from one topic to another. The client’s speech does not exhibit this pattern.
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