Nursing Elites

1. A client's medication sheet contains a prescription for sertraline (Zoloft). To ensure safe administration of the medication, a nurse would administer the dose:

• A. On an empty stomach
• B. At the same time each evening
• C. Evenly spaced around the clock
• D. As needed when the client complains of depression

Correct answer: B

Rationale: The correct answer is B: 'At the same time each evening.' Sertraline should be administered at the same time each evening to maintain steady drug levels and effectiveness. Choice A is incorrect because sertraline can be taken with or without food. Choice C is incorrect as sertraline does not need to be spaced around the clock. Choice D is incorrect as sertraline is a scheduled medication and should not be taken on an as-needed basis for complaints of depression.

2. A 30-year-old sales manager tells the nurse, 'I am thinking about a job change. I don't feel like I am living up to my potential.' Which of Maslow's developmental stages is the sales manager attempting to achieve?

• A. Self-Actualization
• B. Loving and Belonging
• C. Basic Needs
• D. Safety and Security

Correct answer: A

Rationale: The correct answer is 'Self-Actualization.' Self-actualization is the highest level of Maslow's hierarchy of needs, focusing on fulfilling one's full potential and achieving personal growth. In this scenario, the sales manager expressing a desire for a job change because they don't feel they are living up to their potential aligns with the characteristics of self-actualization. Choices B, C, and D represent lower levels of Maslow's hierarchy: 'Loving and Belonging' pertains to social needs, 'Basic Needs' encompass physiological and safety needs, and 'Safety and Security' are fundamental needs related to protection and stability.

3. An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, 'Where should I stand for the parade?' Which response is best for the nurse to provide?

• A. "You can stand wherever you'd like as long as you stay safe from those in the parade."
• B. "You seem confused because of all the activity in the hall. There is no parade."
• C. "Let's go back to the activity room and see what is going on in there."
• D. "Remember, this is a nursing home, and I am here to help you."

Correct answer: C

Rationale: (C) is the best response as it redirects the client to a safer, familiar place. (A) is dismissive and does not address the client's needs directly. (B) labels the behavior, which may increase the client's anxiety. (D) is scolding and may not be helpful in the situation.

4. A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin decanoate) is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation in the Bahamas and will return in 18 days. Which statement by the client indicates a need for health teaching?

• A. "When I return from my tropical island vacation, I will go to the clinic to get my Prolixin injection."
• B. "While I am on vacation and when I return, I will not consume any alcohol-containing food or beverages."
• C. "I will inform the healthcare provider if I develop a sore throat or flu-like symptoms."
• D. "I will maintain my daily intake of benztropine mesylate (Cogentin)."

Correct answer: A

Rationale: Photosensitivity is a side effect of Prolixin, and a vacation in the Bahamas (with its tropical island climate) increases the client's risk of experiencing this side effect. Therefore, the client should be advised to avoid direct sun exposure. Choice A indicates a need for health teaching as the client plans to return from vacation in 18 days, which is earlier than the scheduled dose of Prolixin at 20 days after discharge. Choices B, C, and D demonstrate accurate knowledge. Choice B is important because alcohol can interact with Prolixin. Choice C is relevant as it mentions signs of agranulocytosis, a potential side effect of Prolixin. Choice D is correct as benztropine mesylate is used to prevent extrapyramidal symptoms associated with Prolixin.

5. The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which complaint related to administration of this drug should the nurse expect this client to make?

• A. My mouth feels like cotton.
• B. That medication gives me indigestion.
• C. This pill gives me diarrhea.
• D. My urine looks pink.

Correct answer: A

Rationale: Dry mouth is a common side effect of MAO inhibitors like phenelzine due to their anticholinergic effects. Choices B, C, and D are incorrect as indigestion, diarrhea, and pink urine are not commonly associated side effects of phenelzine.

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