a patient with major depressive disorder is started on fluoxetine what is the most important side effect the nurse should monitor for
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Nursing Elites

ATI RN

ATI Mental Health Practice A

1. When a patient with major depressive disorder is started on fluoxetine, what is the most important side effect for the nurse to monitor?

Correct answer: B

Rationale: When initiating fluoxetine therapy in a patient with major depressive disorder, monitoring for suicidal ideation is crucial due to the increased risk of suicidal thoughts or behaviors that can occur, especially in the initial phase of treatment. This close monitoring is essential to ensure patient safety and intervene promptly if such symptoms arise. Weight gain, hypertension, and hyperglycemia are potential side effects of some medications used to treat depression, but suicidal ideation is the most critical and immediate side effect to monitor for when starting fluoxetine.

2. After fasting from 10 p.m. the previous evening, a client finds out that the blood test has been canceled. The client swears at the nurse and states, 'You are incompetent!' Which is the nurse's best response?

Correct answer: B

Rationale: In this scenario, the most appropriate response for the nurse is option B. By acknowledging the client's feelings and setting a boundary regarding inappropriate behavior, the nurse addresses the situation with empathy. This response demonstrates understanding of the client's emotions while also maintaining a professional standard by expressing discomfort with swearing. Option A could come off as defensive and may escalate the situation. Option C may be perceived as condescending and not immediately address the client's behavior. Option D, although offering space, does not directly address the inappropriate behavior and misses an opportunity to set a professional boundary.

3. A healthcare professional is assessing a client with bipolar disorder who is experiencing a depressive episode. Which of the following findings should the healthcare professional expect? Select one that does not apply.

Correct answer: A

Rationale: During a depressive episode in bipolar disorder, clients typically exhibit low energy levels, feelings of hopelessness, insomnia or hypersomnia, and decreased appetite. High energy levels are more commonly seen in manic episodes of bipolar disorder.

4. Which statement made by the nurse demonstrates the best understanding of nonverbal communication?

Correct answer: B

Rationale: Checking for congruence between verbal and nonverbal communication helps validate the patient's response.

5. A client with bipolar disorder is experiencing a depressive episode. Which of the following interventions should the nurse avoid implementing?

Correct answer: D

Rationale: In caring for a client with bipolar disorder in a depressive episode, the nurse should implement interventions that promote mental well-being. Encouraging participation in activities, promoting adequate nutrition and hydration, and monitoring for suicidal ideation are all essential components of care. Discouraging verbalization of feelings is counterproductive as it hinders the therapeutic process and communication, which are crucial for the client's emotional expression and recovery.

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