Which finding necessitates immediate nursing action for a child being treated for depression with a selective serotonin reuptake inhibitor (SSRI)?
a. Oversedation
b. Behavioral activation
c. Anticholinergic effects
d. Extrapyramidal symptoms
B
Behavioral activation, a common side effect of SSRI therapy, is demonstrated by motor restlessness, insomnia, hypomania, and disinhibition. Suicidal thoughts and planning are thought to be associated with behavioral activation, so individuals should be monitored closely as depression lifts. The other drug side effects are associated with typical antipsychotics and tricyclic antidepressants.
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Anticipatory guidance is an effective means of preventing injury. Some outdoor safety education for the caregiver should include which of the following?
1. Never leave children unattended near pools, ponds, lakes, or any body of water, even if they can swim. 2. When playing on the playground, children should be taught not to run in roped areas and not to jump on trampolines. 3. Children should wear a helmet when riding a bicycle or skating and should not ride a bike or skate in the street. 4. All of the above
An appropriate goal for the patient with a nursing diagnosis of spiritual distress related to intense pain and suffering as verbalized by the patient would be that the patient will
A) Express feelings of anger and despair to God B) Have a minister meet with the patient daily C) Reflect on past accomplishments in life D) Participate in supportive spiritual practices
Which of these clients who have just arrived in the emergency department should the nurse classify as emergent and needing immediate medical evaluation?
A. The 60-year-old with venous insufficiency who has new-onset right calf pain and tenderness B. The 64-year-old with chronic venous ulcers who has a temperature of 100.1° F (37.8° C) C. The 69-year-old with a 40-pack-year cigarette history who is reporting foot numbness D. The 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic
If a nurse suspects a patient has a bowel impaction, which drugs should not be administered?
A. Anti-diarrheals like Bismuth salts (Pepto Bismol) B. Lactulose C. Antacids like Aluminum Hydroxide