Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reinforcing teaching with an older adult client who has major depressive disorder and a prescription for nortriptyline 25 mg daily. Which of the following client statements indicates understanding of the teaching?
A. "I should sit on the side of the bed before standing up in the morning.".
This statement demonstrates an understanding of orthostatic hypotension, a potential side effect of nortriptyline. Nortriptyline, a tricyclic antidepressant, can cause postural hypotension, which puts the client at risk for dizziness and falls when standing up suddenly. Sitting on the side of the bed before standing helps the client adjust to the change in position gradually, minimizing the risk of orthostatic hypotension.
B. "I should take my nortriptyline before breakfast.".
This statement is incorrect. Nortriptyline should be taken with food to minimize gastrointestinal side effects. Taking it before breakfast can lead to an empty stomach, increasing the likelihood of nausea or gastric irritation.
C. "I will avoid drinking caffeinated beverages.".
This statement is not directly related to the medication nortriptyline. Avoiding caffeinated beverages is important for clients taking selective serotonin reuptake inhibitors (SSRIs), but it is not a crucial consideration for nortriptyline.
D. "I can no longer eat pepperoni pizza.".
This statement is not relevant to the teaching about nortriptyline. Pepperoni pizza consumption is not directly linked to the medication's effects or interactions.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom Psych Nursing Spring 2023 Proctored Exam 3. Take the full exam now
Similar Questions
A nurse is planning care for a client newly admitted with major depressive disorder. Which of the following actions should the nurse plan to take?
A. Teach the client to use passive communication when interacting with others.
This choice is incorrect. Passive communication involves avoiding expressing one's needs, feelings, or opinions, which can hinder effective communication. Teaching a client with major depressive disorder to use passive communication is counterproductive, as assertive communication is more beneficial for their overall well-being.
B. Limit the client's involvement in unit activities.
This choice is incorrect. Isolating the client by limiting their involvement in unit activities can exacerbate feelings of depression and loneliness. Encouraging engagement in appropriate unit activities can help improve mood and social interactions.
C. Determine the client's need for assistance with grooming.
This choice is incorrect. While determining the client's need for assistance with grooming is a part of care planning, it is not the most appropriate action for a client with major depressive disorder. The question doesn't provide enough context to determine why grooming assistance is highlighted.
D. Ask the client to create her own schedule of daily activities.
This is the correct choice. Allowing the client to create their own schedule of daily activities empowers them to take an active role in their recovery. It can help restore a sense of control and structure in their life, which is particularly important for individuals with major depressive disorder.
A student nurse caring for a depressed patient reads in the patient's medical record: "This patient clearly shows the vegetative signs of depression." What can the student expect to observe?
A. Feelings of hopelessness, helplessness, and worthlessness.
This choice is incorrect. Feelings of hopelessness, helplessness, and worthlessness are psychological symptoms associated with depression but are not categorized as vegetative signs. Vegetative signs of depression primarily involve disruptions in basic bodily functions.
B. Constipation, anorexia, sleep disturbance.
This is the correct choice. Vegetative signs of depression refer to physical symptoms that are related to basic bodily functions. Constipation, anorexia (loss of appetite), and sleep disturbances (such as insomnia) are examples of vegetative signs that often accompany depressive episodes.
C. Anxiety and psychomotor agitation.
This choice is incorrect. Anxiety and psychomotor agitation are emotional and behavioral symptoms of depression but are not considered vegetative signs. Vegetative signs are more focused on disruptions in bodily functions.
D. Suicidal ideation.
This choice is incorrect. Suicidal ideation is a serious and concerning symptom of depression, but it is not classified as a vegetative sign. Vegetative signs are more related to changes in bodily functions rather than specific thoughts or ideation.
A nurse notices that a client who has moderate anxiety is pacing the hall and mumbling. As the nurse approaches the client, he states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?
A. "Providers usually recommend relaxation exercises for clients who are as upset as you are.".
Recommending relaxation exercises might not be the most appropriate response in this situation. The client is already exhibiting moderate anxiety and pacing, suggesting a high level of distress. Offering relaxation exercises as a first response might not effectively address the immediate need for support and intervention.
B. "An antianxiety pill works best for situations like this.".
Suggesting an antianxiety pill as the best solution oversimplifies the situation. While medication might be a valid consideration, jumping to this option without further assessment or exploration of the client's feelings could be premature and neglectful of potential underlying concerns.
C. "Come with me to an area where we can talk without interruption.".
This is the correct choice. The nurse's response prioritizes creating a safe and supportive environment for communication. Taking the client to a quieter area demonstrates empathy and acknowledges the client's distress, offering an opportunity to address their concerns without distractions.
D. "Most clients with anxiety issues benefit from lying down.".
Suggesting that most clients benefit from lying down oversimplifies the management of anxiety issues. While rest and relaxation are generally important, it doesn't specifically address the client's immediate distress or provide a suitable avenue for open communication.