RQ 6
The 10-year-old client has begun to sleepwalk, a parasomnia disorder. Which information should the nurse provide the parents of the child? Select all that apply.
"Place a lock on the outer door beyond the child's reach." "Guide the child back to bed and let them remain asleep."
The client diagnosed with a major depressive disorder asks the nurse, "Why did my psychiatrist prescribe a selective serotonin reuptake inhibitor (SSRI) medication rather than another type of antidepressant?" Which statement by the nurse is most appropriate?
"SSRIs have fewer side effects than other classifications."
Which instructions should the nurse discuss with the client prescribed oral contraceptives for birth control? Select all that apply.
"Take a missed pill as soon as you realize you have missed it." "Antibiotics will decrease the ovulation suppression effect of the pill." "Notify the HCP if you experience a severe headache."
The mother of a male child diagnosed with ADHD tells the school nurse she does not want her son to take methylphenidate and wants to know about other medications her son could take. Which statement is the nurse's best response?
"There is a nonstimulant medication called atomoxetine that your child could take."
The client diagnosed with infertility tells the clinic nurse about taking St. John's wort for depression. Which statement is the nurse's best response?
"This herb may cause infertility problems."
The nurse is caring for a client diagnosed with menopause and prescribed paroxetine mesylate for hot flashes. The client tells the nurse, "I am concerned about taking hormone therapy for my symptoms." Which statement is the nurse's best response?
"This medication does not contain any hormones."
The female client is taking clomiphene. Which statement indicates the client understands the risk of taking this medication?
"This medication may increase my chance of having twins."
The client with a history of substance abuse is brought to the ED by a friend. The client has a staggering gait and reports feeling short of breath. The client's vital signs are populated in the following vital sign flowsheet. Which question should the nurse ask the client's friend?
"Through which route and at what time did your friend take cocaine?"
The sexually active male adolescent tells the school nurse, "I am embarrassed, but I don't know anyone else to tell. Last night when I used a condom with my girlfriend, I got a red itchy rash down there. I don't know what it is or what to do." Which statement is the nurse's best response?
"Use a condom made out of a lamb's intestines."
The female client tells the nurse that she is taking the herb Jasminum grandiflorum (jasmine) to improve her mood and decrease insomnia. Which response by the nurse is most appropriate?
"You should stop taking this herb immediately; it can cause miscarriages."
The client diagnosed with insomnia asks the nurse, "Why did my HCP prescribe zolpidem and tell me to quit taking acetaminophen and diphenhydramine?" Which response by the nurse is most appropriate?
"Zolpidem will help you get to sleep and stay asleep through the night."
The client wants to quit smoking cigarettes. The client has been to a smoking cessation support group and has used nicotine patches but has not been successful. Which recommendation should the nurse give the client?
"Ask your HCP for a prescription for bupropion."
The client diagnosed with depression is prescribed phenelzine. Which statement by the client indicates to the nurse the medication teaching is effective?
"At a family cookout, I had chicken instead of a hot dog."
After returning from the war 1 month ago, the client is diagnosed with post-traumatic stress disorder (PTSD) and prescribed paroxetine. The client asks the nurse, "Will this medication really help me? I don't like feeling this way." Which statement is the nurse's best response?
"Because the traumatic event was within 1 month, the paroxetine should be helpful."
The client being admitted to the medical unit gives the nurse a list of medications taken at home. Which question should the nurse ask the client?
"Do you have difficulty sleeping at night?"
The nurse is providing discharge instructions for the postpartum client concerning birth control methods. Which question is most important for the nurse to ask the client?
"Has your doctor discussed when to resume sexual activity?"
The client is prescribed fluoxetine for a diagnosis of clinical depression after the client's spouse died. Which question should the nurse ask the client when discussing this medication?
"How do you feel about taking this medication?"
A client in the medical unit has been having nothing by mouth (NPO) for 3 days and is reporting a headache. What should the nurse ask the client to determine the cause of the headache?
"How often do you drink caffeinated beverages?"
The client diagnosed with paranoid schizophrenia has been taking haloperidol for several years. Which statement indicates the client needs additional teaching concerning this medication?
"I am more susceptible to colds and the flu when taking this medication."
The 14-year-old adolescent diagnosed with ADHD is taking lisdexamfetamine. Which statement indicates to the nurse that the adolescent understands the medication teaching?
"I hate that I have to go to the school nurse to take my medication." high abuse potential and is not allowed to be carried by students in the school.
The client diagnosed with panic disorder is taking a phenelzine. Which statement by the client warrants immediate intervention?
"I have been taking dextromethorphan for my cough."
The male client diagnosed with schizophrenia is prescribed ziprasidone. Which statement to the nurse indicates the client understands the medication teaching?
"I may have trouble sleeping when I take this medication."
The client diagnosed with bipolar disorder is taking lithium. Which statement by the client warrants further clarification by the nurse?
"I really enjoy playing soccer on weekends."
The nurse is teaching a pregnant client diagnosed with tuberculosis (TB) infection about treatments during pregnancy and effects on her newborn. Which statement indicates the client understands the teaching?
"I should take supplemental pyridoxine during my pregnancy."
The client has been taking birth control pills for 5 weeks. Which statement from the client warrants intervention by the clinic nurse?
"I stay nauseated, and my breasts are very tender."
At a preconception visit, the nurse instructs the client on the importance of folic acid to prevent serious congenital disabilities. Which statement to the nurse indicates the client needs more teaching?
"I will increase my intake of milk, yogurt, and fish."
Which statements indicate the client diagnosed with bipolar disorder and taking lithium understands the medication teaching? Select all that apply.
"I will make sure I do not get dehydrated." "I should take the medication with food."
Which statement indicates to the nurse the client using a vaginal contraceptive ring understands the birth control teaching?
"I will remove the ring 3 weeks after I have inserted it."
The pregnant client is prescribed ferrous sulfate. Which statement indicates to the nurse the client needs more teaching?
"I will take a daily stool softener to prevent becoming constipated."
The client diagnosed with a major depressive disorder is prescribed duloxetine. The client tells the nurse, "I am going to take my medication at night instead of in the morning." Which statement is the nurse's best response?
"It is all right to take the medication at night. It may help you sleep."
The 7-year-old child newly diagnosed with ADHD is prescribed methylphenidate as a sustained-release tablet. Which information should the nurse discuss with the parents? Select all that apply.
"Keep a behavior diary on your child."
The nurse is discussing fertility issues. Which statement indicates the couple is knowledgeable of fertility issues?
"A multifetal pregnancy can result in preterm labor and birth."
The 24-year-old female client diagnosed with bipolar disorder is prescribed valproic acid. Which question should the nurse ask the client?
"Are you taking any type of birth control?"
The HCP has prescribed lorazepam for a female client receiving chemotherapy reporting an inability to sleep. Which information should the nurse teach the client?
"Do not attempt to become pregnant while taking lorazepam."
The client prescribed an antidepressant 1 week ago tells the psychiatric clinic nurse, "I really don't think this medication is helping me." Which statement by the psychiatric nurse is most appropriate?
"It takes about 3 weeks for your medication to work."
The client diagnosed with obsessive-compulsive disorder (OCD) is prescribed sertraline. Which statement indicates the client understands the medication teaching?
"It will take a couple of months before I see a change in my behavior."
Which statement indicates to the nurse that the male client prescribed testosterone pellets for a low testosterone level understands the teaching concerning testosterone pellets?
"The testosterone pellets will last for 3 to 6 months."
The client, after being raped, is admitted to the emergency department and tells the nurse, "I will kill myself if I get pregnant by this monster." Which statement is the nurse's best response?
"There are medications that can be taken within 72 hours to prevent pregnancy."
Which interventions should the nurse implement when the nurse anesthetist is administering spinal anesthesia to a pregnant client in labor? Select all that apply.
1. Administer 500 to 1,000 mL of IV fluid before insertion of the spinal catheter. 2. Instruct the client to lie on her side in the fetal position during spinal catheter insertion. 3. Perform a neurovascular assessment on the client's lower extremities. 4. Monitor the client's blood pressure, pulse, and respirations during spinal anesthesia. 5. Assist the client with pushing when instructed by the obstetrician.
The labor and delivery nurse is preparing the client for a scheduled cesarean birth. Which interventions should the nurse expect to implement? Select all that apply.
1. Administer famotidine or sodium citrate with citric acid. 2. Perform an abdominal prep with an antiseptic containing chlorhexidine and alcohol. 3. Give cephazolin via intravenous piggyback (IVPB). 5. Perform a "time-out" procedure.
The client diagnosed with neonatal abstinence syndrome (NAS) is irritable, having difficulty feeding, and sleeping poorly. Which interventions should the nurse expect to implement? Select all that apply.
1. Administer morphine orally. 3. Give phenobarbital to control seizures. 4. Collaborate with child protective services. 5. Perform gavage feeding.
The client admitted to the psychiatric unit for a diagnosis of major depressive disorder and attempted suicide is prescribed an antidepressant medication. Which interventions should the psychiatric nurse implement? Select all that apply.
1. Assess the client's apical pulse and blood pressure. 3. Monitor the client's liver function status. 4. Provide for and ensure the client's safety.
The nurse is preparing to administer erythromycin ophthalmic ointment to a newborn client. Which interventions should the nurse implement? Select all that apply.
1. Cleanse the client's eyes before application as needed. 2. Apply a thin ribbon of medication to each eye in a single dose. 3. Administer from the inner canthus to the outer canthus.
The nurse is teaching the client about medications and diet during lactation. Which information should the nurse include in the teaching? Select all that apply.
2. "Do not take over-the-counter (OTC) decongestants such as pseudoephedrine." 3. "Too much caffeine can cause irritability and wakefulness in the newborn."
Which client would be most appropriate to prescribe disulfiram?
A highly motivated client wanting to quit drinking alcohol
The female client has been taking infertility medications. Which findings indicate ovarian overstimulation syndrome?
A positive fluid wave and lower abdominal wave
The male client is diagnosed with narcolepsy. Which OTC preparations should the nurse teach the client about?
Caffeinated beverages and diphenhydramine
The client diagnosed with chronic alcoholism is admitted to the medical unit for pneumonia. Which medication should the nurse expect the HCP to prescribe to prevent delirium tremens?
Chlordiazepoxide
Which diagnostic test should the nurse expect the HCP to monitor for the child diagnosed with ADHD and prescribed methylphenidate?
Complete blood count (CBC)
The nurse is caring for the preterm infant in the NICU prescribed aminoglycosides and loop diuretics. Which adverse reaction can occur from combining these two types of medications?
Hearing loss
The premature newborn client is diagnosed with a patent ductus arteriosus (PDA) and is experiencing labored breathing and an increased need for oxygen. Which medication would the nurse anticipate the HCP to order? Select all that apply.
Indomethacin Ibuprofen Caffeine
The client diagnosed with paranoid schizophrenia is prescribed aripiprazole. Which statement best describes the scientific rationale for administering this medication?
It reduces positive symptoms of schizophrenia and improves negative symptoms.
The day shift nurse finds an elderly client difficult to arouse during the initial morning shift assessment. The nurse reviews the client's medication record for the last 24 hours. Which intervention should the nurse implement first?
Make sure the client has a call light within reach.
The client has taken alprazolam daily for the past 2 years. Which clinical manifestations would warrant intervention by the nurse?
Nausea, vomiting, and agitation
The client diagnosed with a 32-week pregnancy and preterm labor is prescribed terbutaline. The client's vital signs are populated in the following vital sign flowsheet. Vital Sign FlowsheetClient ValuesReference Values Temperature 98°F/36.7°C Oral: 98°F (36.7°C) Pulse 104 bpm 60 to 100 bpm Respirations 34 breaths/min 12 to 20 breaths/min Blood pressure 112/60 mm Hg 100 to 119 mm Hg systolic 60 to 80 mm Hg diastolic Fetal heart rate (FHR) 150 bpm 110 to 160 bpm (at term) Which data warrants intervention by the nurse?
Respiratory rate
The nurse is caring for a pregnant client who delivered her last baby at 30 weeks gestation. The HCP has prescribed hydroxyprogesterone caproate injections. Which information should the nurse discuss with the client? Select all that apply.
1. "This medication lowers the risk of having another preterm infant." 2. "Injections are given weekly from 16 to 37 weeks gestation." 4. "Pain, redness, and swelling can occur at the injection site."
The client diagnosed with schizophrenia is prescribed clozapine. Which information should the nurse discuss with the client concerning this medication? Select all that apply
1. Discuss the need for regular exercise. 2. Instruct the client to monitor for weight gain. 3. Encourage the client to quit smoking cigarettes.
Which information should the nurse discuss with the client diagnosed with schizophrenia and prescribed an atypical antipsychotic medication? Select all that apply.
1. Drink decaffeinated coffee and tea. 4. Report muscle spasms and rigidity. 5. Monitor glucose levels and lipid levels.
The nurse is caring for the client before inserting prostaglandin E2 dinoprostone for cervical ripening. Which interventions should the nurse implement? Select all that apply.
1. Ensure the client has signed informed consent for the procedure. 2. Instruct the client to void before medication insertion. 3. Have the client maintain a recumbent position for 2 hours after administration. 4. Prepare to remove the insert in the event of an adverse reaction.
The nurse is preparing the newborn for circumcision using a Gomco clamp. Which interventions should the nurse implement? Select all that apply.
1. Ensure vitamin K was administered at birth. 2. Apply a eutectic mixture of lidocaine and prilocaine. 4. Obtain petroleum jelly to place on the penis after the procedure. 5. Administer acetaminophen orally before the procedure.
The nurse is caring for the pregnant client in labor. The client has had no prenatal care and reports being dependent on opioids throughout her pregnancy. Which interventions for pain control could be provided to this client? Select all that apply.
1. Epidural anesthesia 3. Morphine IV 4. Acetaminophen PO 5. 1% lidocaine locally
The client diagnosed with a major depressive disorder is prescribed brexpiprazole in addition to their antidepressant. Which information should the nurse teach? Select all that apply.
1. Inform the client that weight gain can occur. 2. Teach the client to report urges to gamble, impulse shop, or binge eat. 4. Advise the client to avoid saunas or hot tubs. 5. Explain to the client the need to rise slowly from a sitting position.
The nurse is leading a medication group in a psychiatric unit. Which information should the nurse discuss with the client concerning antipsychotic medications after discharge? Select all that apply.
1. Instruct the client to chew sugarless gum to help dry mouth. 2. Teach the client about orthostatic hypotension. 3. Discuss that these medications may cause sexual dysfunction. 4. Instruct the client to call the HCP if flu-like symptoms occur.
The pregnant client diagnosed with bipolar disorder has been taking lamotrigine to control symptoms. The client asks the nurse for information about the medication and pregnancy. Which information should the nurse tell the client? Select all that apply.
1. Lamotrigine is the preferred treatment for bipolar disorder in pregnancy. 2. Medication dosage may need to be increased during pregnancy. 3. Serum lamotrigine levels should be obtained every 4 weeks in pregnancy. 5. Lamotrigine causes no significant increase in birth defects.
The nurse is preparing an amnioinfusion for a client experiencing severe variable decelerations of the FHR. Which solution should the nurse expect to administer through the intrauterine pressure catheter? Select all that apply.
1. Normal (0.9%) saline. 3. Lactated ringer's
Based on the following assessment of the newborn client, which interventions should the nurse perform? Select all that apply.
1. Suction the mouth and nose. 2. Provide oxygen via a face mask. 5. Assess for the need to administer naloxone.
The client diagnosed with preeclampsia and 38 weeks pregnant is admitted to the labor and delivery area. The HCP has prescribed IV magnesium sulfate. Which data indicates the medication is effective? Select all that apply.
1. The client has no seizure activity. 4. The client's deep tendon reflexes are 2 to 3+.
The nurse is teaching the pregnant client diagnosed with HIV about methods to prevent transmission to the infant. Which information should the nurse discuss with the client? Select all that apply.
1. The client will take zidovudine PO regularly, beginning at 12 to 14 weeks gestation. 2. The client's newborn should receive oral zidovudine 8 to 12 hours after birth. 4. If treated in early pregnancy, risk of HIV transmission to the infant is 1% or less.
The nurse is caring for a healthy newborn client. Which vaccination should the nurse expect to administer before the client is discharged? Select all that apply.
1. haemophilus influenzae type b 2. measles, mumps, rubella. 3. diphtheria, tetanus, acellular pertussis 4. hepatitis b
The nurse is assisting the certified registered nurse anesthetist (CRNA) in placing an epidural in a laboring client. Which findings would indicate intravascular injection of the local anesthetic? Select all that apply.
1. tachycardia. 3. tinnitus 5. dizziness.
The pregnant client is diagnosed with preterm labor and the HCP has prescribed nifedipine. Which interventions should the nurse implement? Select all that apply.
1. teach the client that skin flushing and headaches can occur. 3. instruct the client to rise slowly after sitting or lying down. 5. advise the client to avoid grapefruit juice.
The pregnant client is prescribed metoclopramide to treat hyperemesis gravidarum. Which information should the nurse discuss with the client? Select all that apply.
2. "Take the medication 30 minutes before mealtime." 3. "Do not drink any type of alcoholic beverages." 5. "The medication can cause drowsiness that will make driving unsafe."
The client diagnosed with bipolar disorder is taking lithium medication. The client's laboratory values are populated in the chart below. Which treatments should the nurse expect the health-care provider (HCP) to prescribe? Select all that apply.
2. Initiate IV therapy with isotonic sodium chloride. 3. Prepare the client for immediate hemodialysis. 5. Monitor the client's cardiac status on telemetry.
The nurse is reviewing the laboring client's fetal monitor strip. Which order by the HCP should the nurse question?
2. administer butorphanol 1 mg IV push
The client diagnosed with gestational diabetes asks the nurse, "Why do I have to take shots? Why can't I take a pill?" Which statement is the nurse's best response?
2. pils may hurt the development of the baby in your womb. Oral hypoglycemics are not used during pregnancy because they cross the placental barrier; they stimulate fetal insulin production and may be teratogenic.
The pregnant client experienced deep venous thrombosis (DVT) with her previous pregnancy. Which medication should the nurse question administering to this client? Select all that apply.
2. warfarin. 4. rivaroxaban. 5. dabigatran.
The nurse is reviewing the laboratory data of a pregnant client in labor at term gestation. Which intervention should the nurse implement?
3. administer penicillin IVPB
The nurse prepares to administer topical benzocaine to a client with a fourth-degree episiotomy. Which interventions should the nurse implement? Rank in order of performance.
3. check the clients MAR with the identification band. 4. ask the client if she is allergic to any -caine drugs. 2. wash hands and put on nonsterile examination gloves. 1. position the client on their side with the top leg up and forward. 5. apply the benzocaine to the perineal area.
Which medication categories are contraindicated for pregnant clients? Select all that apply.
4. Category D medications have a proven risk of fetal harm and are not prescribed for pregnant clients unless the mother's life is in danger. 5. Category X medications have a definite risk of fetal abnormality or abortion.
Which client should the nurse recommend taking oral contraceptive pills for birth control?
4. the client with a family history of ovarian cancer. While providing birth control for the client, the client also gets a secondary benefit of decreasing ovarian cancer risk.
Which client should the nurse expect the HCP to prescribe methadone?
A client addicted to amphetamines
The client experiencing infertility is receiving menotropin and human chorionic gonadotropin (HCG). Which diagnostic test indicates the medications are effective?
A serum estrogen level
The client diagnosed with schizophrenia is hallucinating and attacking other clients in the psychiatric unit. The client has a PRN order for 50 mg of chlorpromazine IM. The medication comes in a vial with 100 mg per mL. How many milliliters should the nurse administer?
A, 0.5
Which task is most appropriate for the registered nurse (RN) to assign to the licensed practical nurse (LPN) working in the psychiatric department?
Administer alprazolam to a client diagnosed with a panic disorder.
The client diagnosed with chronic alcoholism is prescribed multivitamins via IV route because of malnutrition. The IV solution turns yellow after injecting the multivitamin. Which intervention should the nurse implement?
Administer the medication as prescribed and take no action. his IV therapy is commonly known as a "banana bag" because of the yellow color of the IV solution.
The nurse is preparing to administer lithium to a client diagnosed with bipolar disorder. The client's laboratory values are populated in the chart below. Which intervention should the nurse implement?
Administer the medication.
The nurse administers HCG intramuscularly to the female client diagnosed with infertility. Which instruction should the nurse discuss with the couple regarding this medication? Select all that apply.
Advise the couple to have intercourse on the eve of receiving medication and 3 days after receiving medication. Notify the HCP if you experience swelling of the hands and legs, severe pelvic pain, or shortness of breath.
The nurse is caring for a client reporting a decreased sexual desire. The HCP has prescribed flibanserin. Which information should the nurse discuss with the client? Select all that apply.
Alcohol is contraindicated when taking flibanserin. Flibanserin should be taken orally, once a day, at bedtime.
Which client should the nurse consider at risk for complications when taking sildenafil?
An 87-year-old client diagnosed with glaucoma
The male client diagnosed with chronic obstructive pulmonary disease (COPD) is admitted to the medical unit. During the admission process, the client tells the nurse about the inability to sleep without diazepam every night. Which intervention should the nurse implement?
Ask the HCP for an order for diazepam.
The nurse is preparing to administer alprazolam to a client diagnosed with a generalized anxiety disorder. Which intervention should the nurse implement before administering the medication?
Assess the client's anxiety level.
The client diagnosed with preeclampsia is receiving a magnesium sulfate infusion and delivered vaginally. Despite oxytocin and fundal massage, the client is experiencing heavy bleeding. Which medication should the nurse expect to administer?
Carboprost tromethamine
The pregnant client asks the nurse, "What does category A mean if the doctor orders that medication for me?" Which statement best describes the scientific rationale for the nurse's response?
Category A is the safest medication a client can take when pregnant.
The postpartum client, after delivering via cesarean section, is receiving epidural morphine. The unlicensed assistive personnel (UAP) measures the vital signs and enters the findings in the client's electronic health record for the registered nurse (RN) to review. The following flowsheet is populated with the client's vital signs. Which intervention should the nurse implement first?
Check the client's respiratory rate and pulse oximeter reading.
The client diagnosed with schizophrenia is admitted to the medical department for pneumonia and is exhibiting involuntary movements of the tongue and lips. Which medication should the nurse question administering?
Chlorpromazine adverse reaction to first-generation antipsychotic medications such as chlorpromazine
The nurse on the substance abuse unit is administering medications. Which medication should the nurse question administering?
Clonidine to client with a blood pressure of 88/60
The client is brought to the ED by a friend. The client is hypervigilant, has not slept in 3 days, has dilated pupils, has an apical pulse of 118 bpm, and has a runny nose. Which substance should the nurse suspect the client is abusing?
Cocaine
The nurse is caring for the client diagnosed with preeclampsia and receiving magnesium sulfate intravenously. The laboratory reports to the nurse a critically high magnesium level of 6 mg/dL. Which intervention should the nurse implement?
Continue to monitor the client.
The female client taking lorazepam for panic attacks tells the clinic nurse that she is trying to get pregnant. Which intervention should the nurse implement first?
Determine how long the client has been taking the medication.
The nurse is preparing to administer medication in a labor and delivery unit. Which medication should the nurse question administering?
Dinoprostone to a client diagnosed with asthma can cause asthma attack.
The client diagnosed with insomnia is scheduled for sleep studies. The client provides the nurse with their medication list. Which medication should the nurse instruct the client to avoid taking before the sleep study?
Diphenhydramine
The elderly client being prepped for major abdominal surgery describes taking alprazolam as needed (PRN) many years now for nerves. Which information should the nurse discuss with the HCP?
Discuss prescribing another benzodiazepine medication postoperatively.
The client diagnosed with an anxiety disorder is prescribed alprazolam. The client calls the clinic and reports a dizzy, weak feeling when getting out of the chair. Which intervention should the nurse implement?
Discuss ways to prevent orthostatic hypotension.
The client is having a computed tomography scan and starts having a severe anxiety attack. The HCP prescribed diazepam, IV push (IVP). Which intervention should the nurse implement?
Do not dilute diazepam and inject in a port closest to the client.
After an attempted suicide and then diagnosed with major depression, the client is being discharged from the psychiatric facility after a 2-week stay. Which discharge intervention is most important for the nurse to implement?
Ensure the client has no more than a 7-day supply of antidepressants.
The client in labor has an epidural catheter in place for anesthesia. Which intervention is most important for the labor and delivery nurse?
Ensure the client's legs are correctly positioned in the stirrups.
Which pharmacologic intervention should the nurse discuss with the client requesting help to quit smoking marijuana?
Explain that there is no specific pharmacologic intervention.
The client diagnosed with infertility and endometriosis is prescribed leuprolide. Which information should the nurse discuss with the client? Select all that apply.
Explain that this medication may take 3 to 6 months to work. Tell the client not to drink grapefruit juice when taking this medication.
The client diagnosed with a major depressive disorder has been taking amitriptyline for more than 1 year and tells the psychiatric clinic nurse about wanting to stop taking the antidepressant. Which intervention is most important for the nurse to discuss with the client?
Explain the importance of tapering off the medication.
The woman with Rh negative blood and a follower of the Jehovah's Witnesses faith delivers an Rh positive baby. The HCP prescribed Rho (D) immune globulin for the mother. Which intervention should the nurse implement first?
Explain to the client that Rho (D) immune globulin is a blood product.
The client diagnosed with a general anxiety disorder is prescribed alprazolam. Which information should the clinic nurse discuss with the client? Select all that apply.
Explain to the client this medication is for short-term use. Discuss the importance of not driving due to drowsiness.
The client diagnosed with bipolar disorder is prescribed lithium and later admitted to the psychiatric unit in an acute manic state. Which intervention should the nurse implement first?
Implement care for the client's physiological needs.
The sexually active couple has decided to use a spermicide for birth control. Which information should the nurse discuss with the female partner? Select all that apply.
Insert the spermicide before having sexual intercourse. Teach to apply spermicide in the woman's vagina. Explain this form of birth control will not prevent STIs.
The client admitted to the psychiatric unit experiencing hallucinations and delusions is prescribed risperidone. Which intervention should the nurse implement?
Instruct the client to change positions slowly.
The client experiencing infertility is prescribed bromocriptine. The client calls the clinic nurse and reports that she thinks she may be pregnant. Which intervention should the clinic nurse implement first?
Instruct the client to quit taking the medication.
The adolescent client is prescribed the birth control medication depot medroxyprogesterone. Which interventions should the clinic nurse implement? Select all that apply.
Instruct the client to schedule an appointment every 3 months. Explain that infertility may occur up to 2 years after discontinuing. Tell the client that she will not have to take a pill every day.
The client diagnosed with a major depressive disorder and taking fluoxetine reports feeling confused and restless. The client's vital signs are populated in the following vital sign flowsheet. Which intervention should the clinic psychiatric nurse implement?
Instruct the client to stop taking fluoxetine.
The client is discussing wanting to quit smoking cigarettes with the clinic nurse. Which intervention is most successful in helping the client to quit smoking cigarettes?
Instruct the client to use nicotine replacement therapy, such as a patch.
The client is prescribed methadone. Which intervention should the nurse discuss with the client?
Learn how to prevent orthostatic hypotension.
The mother of a 7-year-old child taking methylphenidate for an ADHD diagnosis calls the pediatric clinic and tells the nurse her daughter has lost 4 pounds in the past 2 weeks. Which action should the nurse implement?
Make an appointment for the child to see the HCP.
Which statement best supports the scientific rationale for pharmacologic treatment in clients diagnosed with substance abuse?
Medications permit safe withdrawal and help prevent relapse.
Which medication for the treatment of postpartum hemorrhage can be administered rectally?
Misoprostol
The 6-year-old child diagnosed with ADHD is admitted to the pediatric department after having an emergency appendectomy. Which intervention should the nurse implement when administering methylphenidate to the child?
Monitor the child's vital signs.
The client is experiencing postpartum hemorrhage and has received methylergonovine. Which intervention is the priority when administering this medication?
Monitor the client's peripad count frequently.
The client diagnosed with obstructive sleep apnea reports falling asleep at inappropriate times. The HCP has prescribed solriamfetol. Which instructions should the nurse give the client about the medication? Select all that apply.
Monitor your blood pressure daily. Notify your HCP of violent or abnormal behaviors.
The nurse is caring for a newborn client after an injection of naloxone hydrochloride IM at delivery. The client's vital signs are populated in the following vital sign flowsheet. Which assessment data indicates the medication is effective?
Naloxone is administered to newborn clients diagnosed with depressed respirations when the mother receives opiates within 4 hours of birth. Naloxone is determined to be effective when the newborn client's respirations are between 30 and 60 breaths per minute.
The client diagnosed with anorexia nervosa is admitted to the medical department for total parenteral nutrition (TPN) because of her emaciated condition. Which task can be delegated to the unlicensed assistive personnel (UAP)? Select all that apply.
Obtain the client's daily weight. Perform a glucometer check every 6 hours.
The mother diagnosed with preeclampsia has received magnesium sulfate during labor and delivery. Which interventions should the nursery nurse implement for the newborn? Select all that apply.
Prepare to administer IV calcium gluconate. Stimulate the baby by tapping the feet.
The conscious client was admitted to the emergency department after an overdose of alprazolam. Which intervention should the nurse implement? Select all that apply.
Prepare to administer the antidote flumazenil IV. Prepare supplies for endotracheal intubation.
The nurse is preparing to administer medications in the antepartum unit. Which medication should the nurse question administering?
Prochlorperazine to a client diagnosed with hyperemesis gravidarum contraindicated.
The client diagnosed with chronic alcoholism comes to the emergency department (ED) reporting no alcoholic drinks in more than 1 week. Which intervention should the ED nurse implement first?
Rehydrate the client with large amounts of IV fluids.
The elderly client diagnosed with a panic attack disorder is in the busy day room of a long-term care facility and appears anxious. The client is starting to hyperventilate, tremble, and sweat. Which intervention should the nurse implement first?
Remove the client from the day room.
The male client diagnosed with infertility asks the clinic nurse about methods to improve fertility. Which interventions should the nurse teach the client? Select all that apply.
Take a multivitamin daily with zinc. Testosterone therapy may help increase your sperm count. Avoid smoking and use of nicotine products.
The nurse is discussing the prescribed antipsychotic medication with a family member of a client diagnosed with schizophrenia. Which information should the nurse discuss with the family member?
Teach the family member what to do in case the client has a seizure.
Which information should the nurse discuss with the client diagnosed with bipolar disorder and taking carbamazepine? Select all that apply.
Tell the client to avoid hazardous activities. Teach the client to wear sunscreen when outdoors.
The client diagnosed with bipolar disorder is prescribed cariprazone. Which interventions should the nurse discuss with the client? Select all that apply.
Tell the client to maintain adequate fluid intake. Encourage the client to avoid alcohol. Explain ways to prevent orthostatic hypotension.
To which client should the nurse question administering lithium?
The 42-year-old client taking a loop diuretic
Which assessment data warrants immediate intervention for the client in labor receiving an oxytocin infusion via pump?
The FHR does not return to baseline.
Which assessment data indicates lisdexamfetamine has been effective for the 8-year-old child diagnosed with ADHD?
The child can sit and play a game for 30 minutes with a friend.
The 10-year-old child diagnosed with attention deficit-hyperactivity disorder (ADHD) is taking methylphenidate. Which assessment data warrants intervention from the pediatric clinic nurse?
The child has multiple bruises on the arm. leukopenia, anemia, or both. It could also be the result of child abuse. Either way, it warrants intervention by the nurse.
Which assessment data indicates quetiapine is effective for the client diagnosed with paranoid schizophrenia?
The client denies having auditory hallucinations.
The nurse is administering medications on a psychiatric unit. Which client should the nurse discuss with the HCP?
The client diagnosed with schizophrenia and is receiving cimetidine
The 14-year-old client is prescribed oral contraceptive medication for menstrual irregularity. Which assessment data indicates the medication is effective?
The client has a period every 28 days.
The female client diagnosed with anorexia nervosa is in the inpatient psychiatric unit receiving olanzapine and therapy. Which data suggests the medications are effective?
The client has a weight gain of 1 kg.
The 43-year-old female client diagnosed with schizophrenia has been taking chlorpromazine for 20 years. Which assessment data warrants discontinuing the medication?
The client has fine, worm-like movements of the tongue.
The clinic nurse is assessing a client 3 weeks after a suicide attempt. The client was prescribed sertraline. Which behavior indicates the medication is effective?
The client has started a new job.
The client diagnosed with bipolar disorder is prescribed carbamazepine. Which data indicates the medication is effective?
The client is able to control extremes between mania and depression.
The 17-year-old adolescent female diagnosed with anorexia is prescribed desipramine. Which data indicates the medication is not effective?
The client is preoccupied with shape and weight.
The client diagnosed with pneumonia is admitted to the medical unit. The nurse notes the client is taking an antidepressant medication. Which data best indicates that the antidepressant therapy is effective?
The client reports a "2" on a 1 to 10 scale, with "10" being very depressed.
The 56-year-old female client tells the nurse that she takes the herb Angelica sinensis (dong quai). Which data indicates to the nurse this medication is effective?
The client reports fewer hot flashes.
The client admitted to the psychiatric unit diagnosed with schizophrenia is prescribed clozapine. Which laboratory data should the nurse evaluate?
The client's white blood cell (WBC) count
The nurse is teaching the early postmenopausal client, prescribed short-term systemic estrogen hormones, about the therapy's benefits. Which information should the nurse include in the teaching? Select all that apply.
Therapy can reduce hot flashes and night sweats. Therapy can aid in the prevention of osteoporosis. Therapy can reduce vaginal dryness and dyspareunia.
The client is prescribed a 28-day oral contraceptive pack. Which statement best describes the scientific rationale for this birth control product?
This ensures that the client will take a pill every day.
Which statement is the scientific rationale for prescribing atomoxetine for a child diagnosed with ADHD?
This medication is a nonstimulant, nonnarcotic that regulates impulse control.
The nurse is preparing a client for in vitro fertilization (IVF). Which statement best describes the scientific rationale for administering supplemental progesterone to this client?
To enhance the receptivity of the endometrium to implantation