Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?

Any history of heart disease.

Familial history of mental illness.

Current weight.

Medication history.

Answer and Explanation

The Correct Answer is D

A. Any history of heart disease: While a history of heart disease is important for general health, it is not the most critical factor prior to initiating sertraline. The nurse should still assess for cardiovascular conditions, but this is not the most pressing concern.

B. Familial history of mental illness: While a familial history of mental illness can inform treatment decisions, it is not the most immediate or critical piece of information before starting sertraline.

C. Current weight: Weight is generally not the primary consideration before starting sertraline. However, weight changes can occur during treatment, but this is more of a concern during the ongoing management of the medication.

D. Medication history: Sertraline, as a selective serotonin reuptake inhibitor (SSRI), can interact with other medications, especially those affecting serotonin levels (e.g., other antidepressants, MAO inhibitors, etc.). It is crucial to assess the client’s current medication history to prevent harmful drug interactions, such as serotonin syndrome. This is the most important information to gather before initiating treatment.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"D"}}

Explanation

A. The client discusses moving to Hawaii instead of returning to rebuild her house.

Defense Mechanism: Fantasy

Explanation: The client may be using fantasy as a way to escape from the painful reality of her situation. Discussing moving to a place like Hawaii, which may represent an idealized and stress-free environment, suggests a desire to avoid confronting the challenges and emotions associated with her current circumstances.

B. The client seems unemotional when talking about needing to rebuild her house.

Defense Mechanism: Isolation

Explanation: Isolation, or emotional isolation, occurs when an individual separates emotions from the events or thoughts associated with them. The client's lack of emotional response when discussing rebuilding her house suggests that she may be isolating her feelings to avoid distress.

C. The client states that she sometimes forgets why she is in the hospital.

Defense Mechanism: Suppression

Explanation: Suppression involves the conscious effort to avoid thinking about distressing thoughts or memories. The client's statement that she sometimes forgets why she is in the hospital may indicate an attempt to suppress or avoid focusing on the traumatic event that led to her hospitalization.

D. The client is frightened that the hospital will burn down.

Defense Mechanism: Denial

Explanation: Denial involves refusing to accept the reality of a situation, which can manifest as irrational fears or beliefs. The client's fear that the hospital will burn down may reflect a form of denial, as she might be projecting her fear of the collapse (a traumatic event) onto another catastrophic event, thereby avoiding dealing with her actual trauma.

Summary of Answers:

A. Fantasy - The client discusses moving to Hawaii instead of returning to rebuild her house.
B. Isolation - The client seems unemotional when talking about needing to rebuild her house.
C. Suppression - The client states that she sometimes forgets why she is in the hospital.
D. Denial - The client is frightened that the hospital will burn down.

A. Spend time sitting in silence with the client. B. Involve the client in a daily exercise program. C. Ask the client to describe her depression. D. Observe for signs of possible psychosis.

Correct Answer is A

Explanation

Choice A rationale:
Spending time sitting in silence with the client can be a therapeutic intervention for someone who is depressed and experiencing delayed responses. It allows the client to feel a sense of presence and support without the pressure to speak or respond immediately.
This approach can help create a safe and non-judgmental environment for the client to express themselves when they are ready.

Choice B rationale:
Involving the client in a daily exercise program may be a beneficial part of the overall care plan for managing depression, but it does not directly address the client's delayed responses during interactions.

Choice C rationale:
Asking the client to describe her depression may be a useful therapeutic intervention to explore the client's feelings and experiences, but it should be done in a way that respects the client's pace and readiness to discuss her emotions.

Choice D rationale:
Observing for signs of possible psychosis is important for assessing the client's mental health, but delayed responses alone may not necessarily indicate psychosis. It's essential to consider the broader clinical picture and conduct a comprehensive assessment.

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Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"D"}}

Explanation

A. The client discusses moving to Hawaii instead of returning to rebuild her house.

B. The client seems unemotional when talking about needing to rebuild her house.

C. The client states that she sometimes forgets why she is in the hospital.

D. The client is frightened that the hospital will burn down.

When the nurse addresses questions to an adult female client who is depressed, the client's responses are delayed. Which intervention should the nurse include in this client's plan of care?

Correct Answer is A

Explanation

Patient Data Exhibits The client has been in IMU unit for 3 days and the physician plans to discharge her home today. Select the client actions that were effective in her treatment.

The nurse is assessing a client whose spouse died of a stroke two weeks ago and who reports having numbness and tingling on the right side of the body. The nurse should consider the client's symptoms may likely be due to which condition.

The nurse plans to use role-playing as a therapeutic measure. Which individual is most likely to benefit from this type of therapeutic intervention?

Patient Data History and Physical Exhibits here What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.

During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2. Which action(s) should the nurse take in response to these findings? (Select all that apply.)

The mother of an 8-month-old infant with profound mental and physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth and development milestones. How should the nurse respond to this mother?