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

Answer and Explanation

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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Correct Answer is B

Explanation

A. Posttraumatic stress response involves reliving traumatic events, flashbacks, and hyperarousal, not specifically avoidance due to anxiety about leaving the home.

B. Agoraphobia is characterized by a fear of situations where escape might be difficult or help unavailable, leading to avoidance behavior such as being unable to leave home. It often co-occurs with panic disorder.

C. Generalized anxiety disorder involves excessive worry about multiple areas of life but not specific avoidance behaviors like agoraphobia.

D. Obsessive-compulsive disorder involves intrusive thoughts (obsessions) and repetitive behaviors (compulsions), but not the avoidance behavior characteristic of agoraphobia.

A. A semi-private room with a roommate who has a similar diagnosis B. A private room close to the nursing station C. A seclusion room until the client's activity level becomes more subdued. D. A private room in a quiet location on the unit

Correct Answer is B

Explanation

A. A semi-private room may not provide enough structure or prevent overstimulation, which could exacerbate manic behavior.

B. A private room close to the nursing station is ideal for a client in the manic phase of bipolar disorder. The nurse can monitor the client's behavior more closely while providing a quiet, private space to prevent overstimulation from other clients.

C. A seclusion room should not be the first option unless the client is a danger to themselves or others, and the client's activity level can usually be managed with more supportive measures.

D. A private room in a quiet location is not ideal because the nurse needs to be able to monitor the client closely and intervene if necessary, which would be more difficult in a remote area.

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A patient with a history of bipolar I disorder is prescribed fluoxetine (Prozac) for a depressive episode. What is the nurse's priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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