Nursing Elites

1. During a mental status examination, which of the following components should be included in the assessment? Select one that doesn't apply.

• A. Appearance and behavior
• B. Thought processes
• C. Mood and affect
• D. The greater the cultural distance from the mainstream of society, the greater the likelihood that the illness will be treated with sensitivity and compassion.

Correct answer: D

Rationale: During a mental status examination, key components to be assessed include the client's appearance and behavior, thought processes, mood and affect, and cognitive function. These components help in evaluating the client's mental health status. The statement about cultural distance and illness treatment is not a part of a mental status examination and is not relevant to the assessment of mental health. Choices A, B, and C are essential components of a mental status examination and contribute to a comprehensive evaluation of an individual's mental well-being.

2. A patient with schizophrenia is prescribed olanzapine. The nurse should monitor the patient for which common side effect?

• A. Weight gain
• B. Hypotension
• C. Hair loss
• D. Hyperthyroidism

Correct answer: A

Rationale: Weight gain is a common side effect of olanzapine, an atypical antipsychotic. Olanzapine is known to cause metabolic changes that can lead to weight gain. Monitoring weight regularly is essential to detect and manage this side effect to prevent associated health risks such as diabetes and cardiovascular issues. Hypotension (choice B) is not a common side effect of olanzapine. Olanzapine is more likely to cause orthostatic hypotension, which is a sudden drop in blood pressure when changing positions. Hair loss (choice C) and hyperthyroidism (choice D) are not typically associated with olanzapine use.

3. 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.

4. A client experiencing alcohol withdrawal is being cared for by a nurse. Which symptom should the nurse identify as a priority to address?

• A. Insomnia
• B. Nausea and vomiting
• C. Increased heart rate
• D. Tremors

Correct answer: C

Rationale: Increased heart rate is a critical symptom to address in a client experiencing alcohol withdrawal as it can indicate potential cardiovascular complications. Monitoring and managing the increased heart rate promptly is essential to prevent adverse outcomes.

5. A client has been prescribed sertraline for depression, and the nurse is providing discharge instructions. Which dietary instruction should the nurse include?

• A. Avoid foods high in sodium.
• B. Avoid foods high in calcium.
• C. Avoid foods high in tyramine.
• D. Avoid foods high in potassium.

Correct answer: C

Rationale: Clients prescribed sertraline should avoid foods high in tyramine to prevent a hypertensive crisis. Sertraline, an antidepressant belonging to the selective serotonin reuptake inhibitor (SSRI) class, can interact with tyramine-rich foods, potentially causing a dangerous increase in blood pressure known as a hypertensive crisis. Choices A, B, and D are incorrect because there is no specific dietary restriction related to sodium, calcium, or potassium intake when taking sertraline.

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