Nursing Elites

1. A client with amyotrophic lateral sclerosis (ALS) has been taking riluzole for two weeks. The nurse notes that the client remains weak with observable muscle atrophy. What action should the nurse take?

• A. Explain that the medication may take time to show improvement in symptoms
• B. Withhold the medication and notify the healthcare provider
• C. Advise the client to undergo liver function tests
• D. Document the assessment findings in the electronic health record

Correct answer: D

Rationale: In this scenario, the nurse's priority is to document the assessment findings in the electronic health record. This action is crucial for maintaining an accurate record of the client's health status and can provide valuable information for the healthcare team. While it is important to monitor the client's response to riluzole, explaining that the medication may take time to show improvement (Choice A) would be more appropriate if the client was expecting immediate results. Withholding the medication and notifying the healthcare provider (Choice B) should not be the initial action without further assessment or guidance. Advising the client to undergo liver function tests (Choice C) is not directly related to the current situation of weakness and muscle atrophy.

2. A client with heart failure develops hyperaldosteronism. What dietary recommendation is essential for managing this condition?

• A. Limit intake of high potassium foods
• B. Replace salt with salt substitute
• C. Monitor skin for excessive bruising
• D. Cover your skin before going outside

Correct answer: A

Rationale: Hyperaldosteronism can lead to increased potassium retention, which can be problematic for individuals with heart failure. Limiting intake of high potassium foods is crucial to prevent hyperkalemia, a condition that can worsen heart failure. Therefore, advising the client to limit high potassium foods is essential in managing hyperaldosteronism in the setting of heart failure.

3. A client with a diagnosis of generalized anxiety disorder is prescribed citalopram. The nurse should instruct the client that this medication may have which potential side effect?

• A. Nausea
• B. Drowsiness
• C. Insomnia
• D. Headache

Correct answer: A

Rationale: The correct potential side effect of citalopram is nausea. Citalopram can cause gastrointestinal disturbances such as nausea, so clients should be advised to take the medication with food if nausea occurs to help minimize this side effect. While other side effects like drowsiness, insomnia, and headache may also occur with citalopram, nausea is a common side effect that clients should be informed about. Drowsiness and insomnia are more commonly associated with other medications used to treat anxiety or depression, such as benzodiazepines or certain antidepressants. Headache is a less common side effect of citalopram compared to nausea.

4. When a client with hepatic encephalopathy is receiving lactulose, which parameter is essential to monitor for a response to the drug?

• A. Serum hepatic enzymes
• B. Fingerstick glucose
• C. Stool color and character
• D. Serum electrolytes and ammonia

Correct answer: D

Rationale: In hepatic encephalopathy, the goal of lactulose therapy is to reduce blood ammonia levels by promoting its excretion in the stool. Therefore, monitoring serum electrolytes and ammonia levels is crucial to assess the effectiveness of lactulose in lowering ammonia levels and improving the client's condition. Options A, B, and C are incorrect because serum hepatic enzymes, fingerstick glucose, and stool color/character are not directly related to monitoring the response to lactulose therapy in hepatic encephalopathy.

5. A client with a diagnosis of depression is prescribed fluoxetine. Which statement by the client indicates the need for further teaching?

• A. I should take this medication in the morning with food.
• B. It may take 1 to 4 weeks to notice improvement in symptoms.
• C. I can stop taking this medication once I feel better.
• D. This medication might make me feel drowsy.

Correct answer: C

Rationale: The correct answer is C. Clients prescribed fluoxetine should not stop taking the medication once they feel better without consulting their healthcare provider. It is essential to complete the full course of treatment as directed by the healthcare provider to prevent relapse or potential worsening of symptoms. Abruptly stopping fluoxetine can lead to withdrawal symptoms and may not effectively manage the condition. Therefore, it is crucial for clients to follow the healthcare provider's guidance regarding the duration of treatment with fluoxetine.

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