Nursing Elites

1. A client is being treated with an antidepressant for major depressive disorder. Which statement by the client indicates a need for further teaching?

• A. I know it may take several weeks before I start feeling better.
• B. I should avoid drinking alcohol while taking this medication.
• C. I will stop taking the medication as soon as I feel better.
• D. I should take the medication at the same time every day.

Correct answer: C

Rationale: Choice C indicates a need for further teaching because stopping antidepressants abruptly can lead to withdrawal symptoms. It is essential for the client to follow the healthcare provider's instructions and complete the full course of medication even if they start feeling better to prevent potential relapse or withdrawal effects.

2. A 60-year-old man presents with fatigue, polyuria, and polydipsia. Laboratory tests reveal hyperglycemia and ketonuria. What is the most likely diagnosis?

• A. Type 1 diabetes mellitus
• B. Type 2 diabetes mellitus
• C. Diabetes insipidus
• D. Hyperthyroidism

Correct answer: A

Rationale: The presentation of a 60-year-old man with fatigue, polyuria, polydipsia, hyperglycemia, and ketonuria strongly suggests type 1 diabetes mellitus. Type 1 diabetes typically presents with acute symptoms due to absolute insulin deficiency, leading to hyperglycemia and ketonuria. Conversely, type 2 diabetes often presents more insidiously and is associated with relative insulin deficiency and insulin resistance. Diabetes insipidus, a condition characterized by excessive thirst and excretion of large amounts of dilute urine, is due to problems with antidiuretic hormone (ADH) and is not associated with hyperglycemia or ketonuria. Hyperthyroidism, while also presenting with symptoms like fatigue, does not typically manifest with hyperglycemia or ketonuria. Therefore, based on the clinical presentation and laboratory findings, the most likely diagnosis in this case is type 1 diabetes mellitus.

3. The client is receiving intravenous (IV) morphine for pain control. Which assessment finding requires the most immediate intervention?

• A. Drowsiness.
• B. Itching.
• C. Nausea.
• D. Respiratory rate of 8 breaths per minute.

Correct answer: D

Rationale: A respiratory rate of 8 breaths per minute indicates severe respiratory depression, a life-threatening side effect of opioid therapy. Immediate intervention is crucial to prevent respiratory failure. Monitoring and managing respiratory status are critical in clients receiving opioids to prevent adverse events. Drowsiness, itching, and nausea are common side effects of morphine but are not as immediately life-threatening as severe respiratory depression.

4. What assessments should the nurse prioritize for a client with portal hypertension admitted to the medical floor?

• A. Assessment of blood pressure and evaluation for headaches and visual changes
• B. Assessment for signs and symptoms of venous thromboembolism
• C. Daily weights and measurement of abdominal girth
• D. Monitoring blood glucose every 4 hours

Correct answer: C

Rationale: In portal hypertension, daily weights and measurement of abdominal girth are crucial assessments to monitor fluid retention and ascites. These assessments help in evaluating the effectiveness of treatment and identifying any worsening of the condition, guiding appropriate interventions. Monitoring blood pressure and assessing for symptoms like headaches and visual changes may be important but are not the priority in this case. Assessing for signs and symptoms of venous thromboembolism is relevant in some situations but not directly related to the primary concerns of portal hypertension.

5. A patient with depression is prescribed fluoxetine. What is an important side effect for the nurse to monitor?

• A. Weight gain
• B. Bradycardia
• C. Dry mouth
• D. Suicidal thoughts

Correct answer: D

Rationale: When a patient with depression is prescribed fluoxetine, the nurse should be vigilant for the potential side effect of increased risk of suicidal thoughts. Fluoxetine, like other antidepressants, may elevate the risk of suicidal thoughts, particularly during the initial phases of treatment. Monitoring the patient for any indications of heightened depression or suicidal ideation is crucial to ensure appropriate interventions are implemented promptly.

Similar Questions