Nursing Elites

1. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up?

• A. Describes life as without purpose.
• B. Exhibits an increase in sweating.
• C. States is often fatigued and drowsy.
• D. Complains of nausea and loss of appetite.

Correct answer: A

Rationale: The correct answer is A. Expressing that life is without purpose can indicate deepening depression or suicidal ideation, which requires immediate attention. While sweating, fatigue, drowsiness, nausea, and loss of appetite can be side effects of duloxetine (Cymbalta), they do not indicate the same level of urgency as a statement suggesting deepening depression or suicidal ideation.

2. A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make?

• A. Did you really believe you were Jesus Christ?
• B. I think you're getting well.
• C. Others have had similar thoughts when under stress.
• D. Why did you think you were Jesus Christ?

Correct answer: C

Rationale: Choice C is the best response because it validates the client's experience by acknowledging that others have had similar thoughts when under stress. This response helps normalize the client's past experiences without judgment, fostering a supportive and empathetic environment. Choices A and D may come off as judgmental or confrontational, potentially making the client feel misunderstood or defensive. Choice B, 'I think you're getting well,' does not address the client's past belief or provide the understanding and validation that Choice C offers.

3. A female client presents to the emergency center with confusion, emotional numbness, and expresses to the nurse a feeling of disbelief that she was raped. The nurse determines the client is in the acute phase of rape-trauma syndrome. What action should the nurse implement first?

• A. Secure samples of vaginal hair combings.
• B. Offer prophylactic antibiotic medication.
• C. Explain the rape protocol to the client.
• D. Implement crisis intervention counseling.

Correct answer: C

Rationale: In cases of rape-trauma syndrome, it is crucial to provide clear information about what to expect during the examination and treatment. This can help the client regain a sense of control and reduce anxiety. Explaining the rape protocol to the client should be the first action to implement. Option A is not the priority at this stage as the immediate focus is on addressing the client's emotional needs and providing support. Option B is not the first action unless medically indicated. Option D, crisis intervention counseling, is important but should come after providing essential information and support to the client.

4. Which action should the nurse implement first for a client experiencing alcohol withdrawal?

• A. Apply vest or extremity restraints.
• B. Give an alpha-adrenergic blocker.
• C. Provide a diet high in protein and calories.
• D. Prepare the environment to prevent self-injury.

Correct answer: D

Rationale: The correct action for the nurse to implement first for a client experiencing alcohol withdrawal is to prepare the environment to prevent self-injury. Clients undergoing alcohol withdrawal are at risk of seizures and other symptoms that may lead to self-harm. By ensuring a safe environment, the nurse can mitigate the risk of injury. Applying restraints (Choice A) should only be considered if less restrictive measures fail, as restraints can agitate the client further. Giving an alpha-adrenergic blocker (Choice B) may be part of the treatment plan for alcohol withdrawal but is not the first action to take. Providing a diet high in protein and calories (Choice C) is important for overall health but is not the priority when addressing immediate safety concerns.

5. Which diet selection by a client who is depressed and taking the MAO inhibitor tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen?

• A. Hamburger, French fries, and chocolate milkshake.
• B. Liver and onions, broccoli, and decaffeinated coffee.
• C. Pepperoni and cheese pizza, tossed salad, and a soft drink.
• D. Roast beef, baked potato with butter, and iced tea.

Correct answer: D

Rationale: Roast beef, baked potato with butter, and iced tea are safe choices as they do not contain tyramine, which must be avoided with MAO inhibitors like Parnate. Tyramine-rich foods like aged cheeses, certain meats, and fermented products can cause a hypertensive crisis when combined with MAO inhibitors. Choices A, B, and C contain foods high in tyramine and are not recommended for individuals taking MAO inhibitors.

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