Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
An adult who has recurrent episodes of depression tells the nurse that the prescribed antidepressant needs to be discontinued because the client is feeling better after taking the medication for the past couple of weeks and does not like the side effects. Which response is best for the nurse to provide?
A. Tell the client to discuss the medication side effects with the healthcare provider.
The nurse supports client autonomy and ensures safe management. The provider can adjust the dose, switch medications, or address side effects appropriately.
B. Tell the client that the medication's side effects will most likely dissipate over time.
Telling the client that side effects will most likely dissipate over time may not be accurate for all individuals and does not address the client’s desire to stop the medication.
C. Inform the client that gradual tapering must be used to discontinue the medication.
Informing the client that gradual tapering must be used to discontinue the medication is crucial. Abruptly stopping antidepressants can lead to withdrawal symptoms and a potential relapse of depression. While true that antidepressants require tapering to avoid withdrawal, this does not address the client's misconception that the medication is no longer needed because they feel improved.
D. Remind the client that feeling better is the therapeutic effect of the medication.
Although true, this response dismisses the client’s concern about side effects and does not address the request to discontinue.
E. None
None
F. None
None
This question is an excerpt from Nurse Dive's nursing test bank - RN Hesi Exit Proctored Exam. Take the full exam now
Full Explanation
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A. Discuss with provider → Correct. The nurse supports client autonomy and ensures safe management. The provider can adjust the dose, switch medications, or address side effects appropriately.
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B. Side effects dissipate → Incorrect. Some antidepressant side effects improve, but others persist. This statement minimizes the client’s concerns and is not therapeutic.
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C. Gradual tapering → Incorrect. While tapering is necessary, the nurse should not instruct discontinuation independently. This is the provider’s role.
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D. Feeling better is therapeutic effect → Incorrect. Although true, this response dismisses the client’s concern about side effects and does not address the request to discontinue.
Similar Questions
The school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In which position should the nurse place the child?
A. Side-lying with the head slightly elevated.
Incorrect- This position is not ideal for managing a nosebleed because it does not promote drainage and may lead to blood flowing down the throat.
B. Standing with the head leaning backward.
Incorrect- Leaning the head backward can cause blood to flow down the throat and may lead to choking or aspiration.
C. Sitting up and leaning forward.
Correct- Placing the child in a sitting position and leaning forward helps prevent blood from flowing down the back of the throat, which can lead to choking or aspiration. Leaning forward allows the blood to drain out through the nostrils.
D. Supine with the legs raised.
Incorrect- Placing the child in a supine position with raised legs is not recommended for managing a nosebleed, as it may lead to blood flowing down the throat.
Full Explanation
A) Incorrect- This position is not ideal for managing a nosebleed because it does not promote drainage and may lead to blood flowing down the throat.
B) Incorrect- Leaning the head backward can cause blood to flow down the throat and may lead to choking or aspiration.
C) Correct- Placing the child in a sitting position and leaning forward helps prevent blood from flowing down the back of the throat, which can lead to choking or aspiration. Leaning forward allows the blood to drain out through the nostrils.
D) Incorrect- Placing the child in a supine position with raised legs is not recommended for managing a nosebleed, as it may lead to blood flowing down the throat.
The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?
A. An adult who is in Buck's traction, and scheduled for hip arthroplasty within the next 12 hours.
Incorrect- Hip arthroplasty is a scheduled procedure, and there is no immediate indication of a critical condition that requires urgent attention.
B. An older client who is receiving packed red blood cells on the third day postoperatively for colon resection.
Correct- Postoperative hemorrhage is a serious complication, and an older client receiving packed red blood cells may be experiencing active bleeding. This situation requires immediate assessment and intervention.
C. An older client with continuous bladder irrigation who is 2 days postoperatively for bladder surgery.
Incorrect- While continuous bladder irrigation requires monitoring, it is not as urgent as a potential postoperative hemorrhage.
D. An adult one day postoperative laparoscopic cholecystectomy requesting pain medication.
Incorrect- Pain management is important, but it is not as urgent as assessing a client who may be experiencing active bleeding.
Full Explanation
A) Incorrect- Hip arthroplasty is a scheduled procedure, and there is no immediate indication of a critical condition that requires urgent attention.
B) Correct- Postoperative hemorrhage is a serious complication, and an older client receiving packed red blood cells may be experiencing active bleeding. This situation requires immediate assessment and intervention.
C) Incorrect- While continuous bladder irrigation requires monitoring, it is not as urgent as a potential postoperative hemorrhage.
D) Incorrect- Pain management is important, but it is not as urgent as assessing a client who may be experiencing active bleeding.
The nurse at the 9-month visit reviews the child's height, weight, and feeding progression history.
What should the nurse advise the parents concerning the child's nutrition? Select all that apply
A. Juice should be avoided in infancy and early childhood
Correct- This is correct advice. Juice is not recommended for infants due to its high sugar content and lack of essential nutrients. It can contribute to excessive calorie intake and dental caries.
B. The majority of the child's calories should be coming from the formula
Incorrect- This is not accurate for a 9-month-old infant. By 9 months, most infants have already started to transition to solid foods, and their primary source of nutrition should be from a variety of solid foods, not formula.
C. The parents can add raw fruit, cheese, or firmly cooked vegetables to the die
Correct- This is correct advice. By 9 months, infants can begin to consume a variety of complementary foods to meet their nutritional needs. Adding raw fruit, cheese, or cooked vegetables can provide important nutrients and help introduce different tastes and textures.
D. The child should probably be eating more times per day
Correct- As infants transition to solid foods, they typically require more frequent meals and snacks to meet their energy and nutrient needs. Breast milk or formula intake may also gradually decrease as solid foods are introduced.
E. The parents should consider using a fluoride supplement
Incorrect- Fluoride supplementation may be considered based on the fluoride content of the water supply and the child's risk of dental caries. However, this advice is not specific to the child's nutrition and feeding progression.
F. The child can now convert to animal milk instead of formula
Incorrect- At 9 months, infants should not transition to whole cow's milk as their main source of nutrition. Breast milk or infant formula remains the primary source of nutrition, and cow's milk can be introduced as a beverage and ingredient in cooking after the first year of life.
Full Explanation
A) Correct- This is correct advice. Juice is not recommended for infants due to its high sugar content and lack of essential nutrients. It can contribute to excessive calorie intake and dental caries.
B) Incorrect- This is not accurate for a 9-month-old infant. By 9 months, most infants have already started to transition to solid foods, and their primary source of nutrition should be from a variety of solid foods, not formula.
C) Correct- This is correct advice. By 9 months, infants can begin to consume a variety of complementary foods to meet their nutritional needs. Adding raw fruit, cheese, or cooked vegetables can provide important nutrients and help introduce different tastes and textures.
D) Correct- As infants transition to solid foods, they typically require more frequent meals and snacks to meet their energy and nutrient needs. Breast milk or formula intake may also gradually decrease as solid foods are introduced.
E) Incorrect- Fluoride supplementation may be considered based on the fluoride content of the water supply and the child's risk of dental caries. However, this advice is not specific to the child's nutrition and feeding progression.
F. Incorrect- At 9 months, infants should not transition to whole cow's milk as their main source of nutrition. Breast milk or infant formula remains the primary source of nutrition, and cow's milk can be introduced as a beverage and ingredient in cooking after the first year of life.