A client with a history of suicide attempts has been taking fluoxetine (Prozac) for one month. The client suddenly presents with a bright affect, rates mood at 9 out of 10, and is much more communicative
Which action should be the nurse's priority at this time? 1. Give the client off-unit privileges as positive reinforcement.
2. Encourage the client to share mood improvement in group.
3. Increase the level of this client's suicide precautions.
4. Request that the psychiatrist reevaluate the current medication protocol.
3
Rationale: The nurse should be aware that a sudden increase in mood rating and change in affect could indicate that the client is at risk for suicide. Suicide risk may occur early during treatment with antidepressants. The return of energy may bring about an increased ability to act out self-destructive behavior.
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An NST in which two or more fetal heart rate (FHR) accelerations of 15 beats per minute (bpm) or more occur with fetal movement in a 20-minute period is termed
a. Nonreactive b. Positive c. Negative d. Reactive
A student nurse questions the nurse about the frequency of administration of antipsychotics, such as risperidone (Risperdal)
The nurse responds by explaining that risperidone (Risperdal) is a newer medication that is effective and has the advantage that it: a. does not cause photosensitivity. b. has fewer serious side effects. c. is less expensive. d. does not cause drowsiness.
The physician has prescribed phenytoin (Dilantin) for a client with diabetes mellitus, type
1. What does the nurse include in the plan of care for this client? 1. Plan to institute safety precautions, as the client is at risk for dizziness and ataxia. 2. Plan to discuss with the physician the need to increase the client's insulin based on serum glucose levels. 3. Plan to assess the client for petechiae, epistaxis, and hematuria. 4. Plan to discuss with the physician the need to decrease the client's insulin based on serum glucose levels.
The nurse is creating a nursing care plan for an obese adult client from another culture who has been recently diagnosed with diabetes mellitus
Which of the following must be assessed prior to developing a list of nursing interventions for this client? 1. Whether men or women are typically served first during meals 2. The client's current health beliefs about their body size and health status 3. The client's preferred utensils 4. The client's cultural choices when eating occasional foods