Medical History: The patient is on Naltrexone 50mg PO once daily and Fluoxetine 20mg PO every morning.

The nurse has reviewed the client’s electronic health record.

Which of the following client findings require immediate follow-up by the nurse? (Select all that apply.)

Sexual behaviors

Frequency of hospitalizations

Sodium level

Hepatitis Viral Study (HAA) results

Answer and Explanation

Correct Answer : C,D

Choice C rationale:

Sodium level is a critical electrolyte that plays a vital role in maintaining fluid balance, nerve and muscle function, and blood pressure. Naltrexone, one of the medications the patient is taking, has the potential to cause hyponatremia (low sodium levels) as a side effect. Hyponatremia can manifest with various symptoms, including headache, nausea, vomiting, confusion, seizures, and even coma in severe cases. Prompt recognition and management of hyponatremia are crucial to prevent serious complications.

Rationale for Immediate

Potential for Hyponatremia: Naltrexone, an opioid antagonist, can interfere with the body's ability to regulate sodium levels, leading to hyponatremia.

Serious Consequences of Hyponatremia: Low sodium levels can disrupt vital bodily functions, potentially causing neurological symptoms, seizures, and even coma.

Need for Prompt Intervention: Early detection and correction of hyponatremia are essential to prevent adverse outcomes.

Monitoring and Management: The nurse should assess the patient's sodium level, monitor for signs and symptoms of hyponatremia, and initiate appropriate interventions as needed, such as fluid restriction or electrolyte replacement.

Choice D rationale:

Hepatitis Viral Study (HAA) results are essential for determining the patient's hepatitis A status. Hepatitis A is a highly contagious liver infection that can cause significant illness. Fluoxetine, the other medication the patient is taking, can potentially cause liver damage in rare cases. Therefore, it's crucial to ensure that the patient does not have hepatitis A before initiating or continuing Fluoxetine therapy.

Rationale for Immediate

Potential Liver Injury: Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), has a rare but potential risk of hepatotoxicity (liver damage).

Hepatitis A Risk: Hepatitis A infection can further exacerbate liver injury, increasing the risk of complications.

Baseline Assessment: HAA results provide information about the patient's hepatitis A status, aiding in risk assessment and management decisions.

Monitoring and Precautions: If the patient tests positive for hepatitis A, the nurse should initiate appropriate precautions to prevent transmission and closely monitor liver function during Fluoxetine therapy.

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Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale: While acknowledging the client's experience is important, this statement does not immediately address the content of the hallucinations, which could be crucial for assessing the client's safety.

Choice B rationale: Asking how often the client hears the voices is useful information for later, but it is not the immediate priority when first addressing auditory hallucinations.

Choice C rationale: Asking what the voices are telling the client is the priority. This helps the nurse assess if the hallucinations include commands or harmful content, which is essential for determining the client's immediate safety and risk of self-harm or harm to others.

Choice D rationale: Explaining that the voices are part of the client's illness can be useful for long-term understanding, but it does not address the immediate need to assess the content of the hallucinations.

A. Psychomotor retardation. B. Decreased self-esteem. C. Euphoria. D. Hallucinations. E. Hallucinations.

Correct Answer is C

Explanation

Choice A rationale:

Psychomotor retardation is a characteristic of depression, not hypomania. In fact, individuals with hypomania typically exhibit psychomotor agitation, which is characterized by increased energy and activity levels.

Psychomotor retardation often manifests as slowed movements, speech, and thought processes. It can significantly impact an individual's ability to perform daily tasks and engage in social interactions.

While psychomotor retardation can occur in various mental health conditions, it is not typically associated with hypomania.

Choice B rationale:

Decreased self-esteem is also a characteristic of depression, not hypomania. Individuals with hypomania typically experience inflated self-esteem and grandiosity.

They may overestimate their abilities, make unrealistic plans, or engage in risky behaviors. This inflated sense of self-worth is often a hallmark feature of hypomania and can contribute to impaired judgment and decision-making.

Choice C rationale:

Euphoria is a hallmark symptom of hypomania. It is characterized by an elevated, expansive, or irritable mood that is persistent and noticeable to others.

Individuals with euphoria often feel excessively happy, cheerful, or optimistic. They may have increased energy, decreased need for sleep, and a heightened sense of well-being.

They may also be more talkative, outgoing, and engage in pleasurable activities more often.

This elevated mood is a core feature of hypomania and is often accompanied by other characteristic symptoms, such as increased activity levels, racing thoughts, and impulsivity.

Choice D rationale:

Hallucinations are not a typical feature of hypomania. They are more commonly associated with psychotic disorders, such as schizophrenia.

Hallucinations involve perceiving things that are not real, such as hearing voices or seeing things that are not there.

While hallucinations can occur in some individuals with hypomania, they are not a defining feature of the condition

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Medical History: The patient is on Naltrexone 50mg PO once daily and Fluoxetine 20mg PO every morning. The nurse has reviewed the client’s electronic health record. Which of the following client findings require immediate follow-up by the nurse? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing auditory hallucinations. What should the nurse say first?

Correct Answer is C

Explanation

A nurse is collecting data from a client who has hypomania. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is attending to a client experiencing acute anxiety. Which of the following actions should the nurse undertake? (Select all that apply.)

A nurse is caring for a client who has depression. After two days of treatment, the nurse notices that the client is suddenly more active and there are no longer signs of a depressive state. Which of the following interventions should the nurse recommend for the plan of care?

A nurse is reviewing the admission laboratory values for a client who has a history of bulimia nervosa. Which of the following findings is the nurse’s priority?

A nurse is assisting with the admission of a client to an acute mental health unit following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions should the nurse take first?

A nurse is making a home visit for a 16-year-old adolescent who attempted suicide. Which of the following behaviors should alert the nurse that the adolescent still has suicidal intent?

A nurse is conversing with a client diagnosed with schizophrenia. Suddenly, the client expresses fear, stating, “I’m scared. Can you hear that? The voices are instructing me to do awful things.” Which of the following responses from the nurse would be suitable?

A nurse is reinforcing teaching with a client about electroconvulsive therapy (ECT). Which of the following information should the nurse include in the teaching?

A nurse facilitating a group therapy session is listening to clients discuss their coping strategies when feeling stressed. Which of the following statements indicate adaptive coping? (Select all that apply.)

Medical History: The patient is on Naltrexone 50mg PO once daily and Fluoxetine 20mg PO every morning.

The nurse has reviewed the client’s electronic health record.

Which of the following client findings require immediate follow-up by the nurse? (Select all that apply.)