Nursing Elites

1. A client with major depressive disorder is prescribed a selective serotonin reuptake inhibitor (SSRI). Which side effect should the nurse educate the client about?

• A. Hypertension.
• B. Sexual dysfunction.
• C. Increased appetite.
• D. Weight gain.

Correct answer: B

Rationale: The correct answer is B: Sexual dysfunction. Sexual dysfunction is a common side effect of SSRIs. While hypertension (A) can occur with other medications, it is not typically associated with SSRIs. Increased appetite (C) and weight gain (D) are potential side effects of some antidepressants, but sexual dysfunction is more specific to SSRIs. Therefore, the nurse should educate the client about the risk of sexual dysfunction when taking an SSRI.

2. A client with schizophrenia is being treated with haloperidol (Haldol) and begins to exhibit symptoms of tardive dyskinesia. What is the nurse's priority action?

• A. Continue the medication and monitor for worsening symptoms.
• B. Administer the next dose of haloperidol with food.
• C. Report the symptoms to the healthcare provider immediately.
• D. Educate the client about the side effects of haloperidol.

Correct answer: C

Rationale: The correct answer is to report the symptoms to the healthcare provider immediately. Tardive dyskinesia is a serious side effect of antipsychotic medications, including haloperidol. Prompt reporting is crucial to evaluate the need for medication adjustment or change in treatment. Continuing the medication without intervention (choice A) can worsen the symptoms. Administering the next dose (choice B) is not appropriate when tardive dyskinesia is suspected. Educating the client (choice D) is important but not the priority when dealing with acute symptoms of tardive dyskinesia.

3. A client with post-traumatic stress disorder (PTSD) reports having frequent nightmares. What is the nurse's best response?

• A. Nightmares are common with PTSD and should decrease over time.
• B. Try to avoid thinking about the trauma before going to bed.
• C. Let's discuss some relaxation techniques you can use before bedtime.
• D. I will ask the healthcare provider to prescribe a sleep aid.

Correct answer: C

Rationale: The best response for the nurse is to discuss relaxation techniques with the client that can help reduce anxiety and stress before bedtime. This approach may potentially decrease the frequency of nightmares by promoting a more calming and peaceful pre-sleep routine. Choice A is incorrect because while nightmares can be common with PTSD, it is not guaranteed that they will decrease over time. Choice B is incorrect as avoiding thinking about the trauma may not address the underlying issue causing the nightmares. Choice D is incorrect as prescribing a sleep aid should be considered as a last resort after trying non-pharmacological interventions.

4. The LPN/LVN is caring for a client who is experiencing alcohol withdrawal. Which intervention should the nurse implement first?

• A. Administer a PRN dose of lorazepam (Ativan).
• B. Monitor the client's vital signs.
• C. Place the client on seizure precautions.
• D. Encourage the client to express feelings about withdrawal.

Correct answer: B

Rationale: When caring for a client experiencing alcohol withdrawal, the first intervention the nurse should implement is to monitor the client's vital signs. Vital sign monitoring is crucial to assess for any potential complications such as hypertension, tachycardia, fever, or other signs of autonomic hyperactivity. Administering medication like lorazepam (Ativan) would come after assessing the vital signs to determine the need for pharmacological intervention. Placing the client on seizure precautions is important, but assessing vital signs takes precedence to ensure immediate safety. Encouraging the client to express feelings about withdrawal is a supportive intervention but does not address the immediate physiological risk associated with alcohol withdrawal.

5. The LPN/LVN is caring for a client who has been prescribed lithium carbonate. What is the most important instruction for the nurse to provide?

• A. Take the medication with food to avoid stomach upset.
• B. Do not change your salt intake while on this medication.
• C. Drink plenty of water and maintain a consistent salt intake.
• D. Avoid excessive intake of caffeine while on this medication.

Correct answer: B

Rationale: The most important instruction for a client prescribed lithium carbonate is not to change their salt intake. Alterations in sodium levels can impact lithium levels, leading to an increased risk of toxicity. Choice A is not crucial for lithium carbonate administration. While hydration is essential, maintaining a consistent salt intake is more critical than just increasing water intake (Choice C). Although caffeine can interact with lithium, it is not as important as maintaining a consistent salt intake (Choice D).

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