Nursing Elites

1. A client has experienced the death of a close family member and at the same time becomes unemployed. This situation has resulted in a 6-month score of 110 on the Recent Life Changes Questionnaire. How should the nurse evaluate this client data?

• A. The client is experiencing severe distress and is at risk for physical and psychological illness.
• B. A score of 110 on the Miller and Rahe Recent Life Changes Questionnaire indicates no significant threat of stress-related illness.
• C. Susceptibility to stress-related physical or psychological illness cannot be estimated without knowledge of coping resources and available supports.
• D. The client may view these losses as challenges and perceive them as opportunities.

Correct answer: C

Rationale: The Recent Life Changes Questionnaire is an expanded version of the Schedule of Recent Experiences and the Rahe-Holmes Social Readjustment Rating Scale. A 6-month score of 300 or more, or a year-score total of 500 or more, indicates high stress in a client's life. However, susceptibility to stress-related physical or psychological illness cannot be accurately estimated without considering the individual's coping resources and available support systems. Positive coping mechanisms and strong social support can mitigate the risk of stress-related illnesses even in the face of significant life changes and losses. Choice A is incorrect because it makes a definitive statement about the client's state without considering individual coping mechanisms and support. Choice B is incorrect because a score of 110 does not necessarily mean no threat of stress-related illness, as individual factors play a crucial role. Choice D is incorrect as it assumes a positive outlook without acknowledging the potential impact of the experienced losses on stress levels.

2. Which of the following is a common side effect of selective serotonin reuptake inhibitors (SSRIs)?

• A. Hypotension
• B. Sexual dysfunction
• C. Increased appetite
• D. Tachycardia

Correct answer: B

Rationale: Corrected Rationale: Sexual dysfunction is a commonly reported side effect of selective serotonin reuptake inhibitors (SSRIs). SSRIs can affect sexual function by causing issues such as decreased libido, delayed ejaculation, erectile dysfunction, or anorgasmia. Patients should be educated about these potential side effects when starting SSRIs to facilitate informed decision-making and appropriate management strategies. Incorrect Choices: A) Hypotension is not a common side effect of SSRIs. C) Increased appetite is not a common side effect of SSRIs. D) Tachycardia is not a common side effect of SSRIs.

3. A client has been prescribed diazepam (Valium) for the treatment of anxiety. Which of the following instructions should the nurse include in the discharge teaching?

• A. Avoid drinking alcohol while taking this medication.
• B. Take the medication with food to avoid stomach upset.
• C. Stop taking the medication if you feel better.
• D. Double the dose if you miss a dose.

Correct answer: A

Rationale: The correct instruction is to avoid drinking alcohol while taking diazepam (Valium) as it can potentiate the sedative effects and increase the risk of side effects such as drowsiness and dizziness. Taking the medication with food may help reduce stomach upset, but avoiding alcohol is crucial to ensure safe and effective use of diazepam. Choice B is partially correct, as taking the medication with food can indeed help with stomach upset, but it is not as crucial as avoiding alcohol. Choice C is incorrect because abruptly stopping diazepam can lead to withdrawal symptoms and should only be done under medical supervision. Choice D is incorrect as doubling the dose is dangerous and should never be done without healthcare provider approval.

4. During a mental health assessment on an adult client, which client action would demonstrate the highest achievement in terms of mental health according to Maslow's hierarchy of needs?

• A. Maintaining a long-term, faithful, intimate relationship
• B. Achieving a sense of self-confidence
• C. Possessing a feeling of self-fulfillment and realizing full potential
• D. Developing a sense of purpose and the ability to direct activities

Correct answer: C

Rationale: In Maslow's hierarchy of needs, self-actualization is the highest level. Possessing a feeling of self-fulfillment and realizing full potential reflects self-actualization. This level represents achieving personal growth, self-improvement, and reaching one's full potential, indicating optimal mental health. Choices A, B, and D represent lower levels of needs according to Maslow's hierarchy. Maintaining a long-term relationship indicates belongingness and love needs, achieving self-confidence pertains to esteem needs, and developing a sense of purpose relates to self-esteem and self-actualization needs, but they are not at the pinnacle of self-actualization as in choice C.

5. Which client statement indicates an understanding of the education provided about the antidepressant medication sertraline (Zoloft)?

• A. I should take this medication on an empty stomach.
• B. It may take several weeks for this medication to be effective.
• C. I can stop taking this medication when I feel better.
• D. I should avoid taking this medication with other medications.

Correct answer: B

Rationale: Choice B is the correct answer. It is crucial for clients to understand that sertraline (Zoloft) may take several weeks to show its full effects. Patients should be informed about this delay in onset of action to set realistic expectations and adhere to the treatment plan. This education helps prevent premature discontinuation of the medication due to perceived lack of efficacy. Choices A, C, and D are incorrect. Choice A is inaccurate because sertraline (Zoloft) should be taken with food to reduce the risk of gastrointestinal side effects. Choice C is incorrect because abruptly stopping the medication can lead to withdrawal symptoms and worsening of the condition. Choice D is inaccurate as there are specific medications that should be avoided with sertraline, but a general statement to avoid all other medications is overly broad and not necessary.

Similar Questions