sad and lonenly
A nurse is planning care for a client who has been taking diazepam for several months and now wants to stop the medication. Which instruction should the nurse include in the teaching?
A. Stop the medication immediately if you feel better.
B. Take the medication only when you feel anxious.
C. Gradually reduce the dose under medical supervision.
D. Take a second dose if anxiety returns.
C. Gradually reduce the dose under medical supervision. ✅
Rationale: Benzodiazepines like diazepam must be tapered to prevent withdrawal symptoms (such as seizures or rebound anxiety).
A nurse is educating a client newly prescribed an SSRI for depression. Which statement by the client indicates a need for further teaching?
A. “I might not feel better right away.”
B. “It could take about 2 weeks to start working.”
C. “I should stop taking it if I don’t see results in a few days.”
D. “I should report any suicidal thoughts to my provider.”
C. “I should stop taking it if I don’t see results in a few days.” ✅
Rationale: SSRIs take several weeks to achieve therapeutic effects; abrupt discontinuation is unsafe.
A client taking phenelzine develops a severe headache and elevated blood pressure. Which action should the nurse take first?
A. Administer acetaminophen.
B. Notify the healthcare provider immediately.
C. Encourage the client to rest quietly.
D. Obtain a blood glucose reading.
B. Notify the healthcare provider immediately. ✅
Rationale: Severe hypertension may indicate a hypertensive crisis caused by tyramine or OTC drug interaction — an emergency.
A nurse is teaching a client about MAOI therapy. Which statement by the client indicates understanding?
A. “I’ll check with my provider before taking any cold medicine.”
B. “I can eat aged cheese and cured meats in moderation.”
C. “This medication won’t affect my blood pressure.”
D. “I’ll stop the medication if I get a headache.”
A. “I’ll check with my provider before taking any cold medicine.” ✅
Rationale: MAOIs interact with OTC drugs and tyramine-rich foods, risking dangerous BP increases.
The nurse is caring for a 12-year-old diagnosed with depression and prescribed an SSRI. What is the priority nursing concern?
A. Risk for weight gain
B. Risk for suicidal ideation
C. Risk for electrolyte imbalance
D. Risk for orthostatic hypotension
B. Risk for suicidal ideation ✅
Rationale: Antidepressants carry a black box warning for increased suicidal thoughts in children, adolescents, and young adults under 25.
Which nursing action has the highest priority for a client taking lithium?
A. Encourage high-protein intake.
B. Restrict fluid intake to 1 L/day.
C. Monitor sodium and fluid balance closely.
D. Limit salt intake completely.
C. Monitor sodium and fluid balance closely.
Rationale: Sodium and lithium compete in the body; dehydration or low sodium can cause toxicity.
A nurse reviews lab results for a client taking lithium. Which findings require immediate intervention?
A. Fine hand tremors and mild thirst
B. Nausea, vomiting, and diarrhea
C. Drowsiness and dry mouth
D. Mild headache and fatigue
B. Nausea, vomiting, and diarrhea ✅
Rationale: GI distress is an early sign of lithium toxicity; levels >2.0 mEq/L are toxic
Which statement by the client taking lithium indicates effective teaching?
A. “I’ll drink plenty of water and keep my sodium intake steady.”
B. “I can stop taking the medication once I feel better.”
C. “I’ll avoid having blood work done unless I feel ill.”
D. “I can skip a dose if I forget to take it on time.”
A. “I’ll drink plenty of water and keep my sodium intake steady.” ✅
Rationale: Ongoing blood level monitoring and stable hydration are essential to prevent toxicity
Before administering oxycodone to a client, what is the nurse’s priority assessment?
A. Bowel sounds
B. Blood pressure
C. Respiratory rate
D. Heart rate
C. Respiratory rate ✅
Rationale: Respiratory depression is the major adverse effect of opioids; hold the dose if RR <12/min.
A nurse is reviewing causes of different types of strokes. Which condition most commonly leads to a hemorrhagic stroke?
A. Atrial fibrillation
B. Carotid artery plaque
C. Hypertension
D. Hypotension
C. Hypertension ✅
Rationale: Chronic hypertension weakens cerebral vessels, leading to rupture and hemorrhage.
A nurse witnesses a client suddenly develop slurred speech and unilateral weakness. What is the nurse’s priority action?
A. Perform a complete neurological assessment.
B. Check blood glucose.
C. Activate the emergency response system.
D. Reassure the client and observe.
C. Activate the emergency response system. ✅
Rationale: Early intervention is critical — “Time is brain.” Immediate emergency activation is required.
A client presents with sudden weakness and absent reflexes. Which question should the nurse ask first?
A. “Have you had any recent cold or flu symptoms?”
B. “Have you traveled recently?”
C. “Are you taking any new medications?”
D. “Do you have a history of head injury?”
A. “Have you had any recent cold or flu symptoms?” ✅
Rationale: GBS often follows a viral or respiratory infection.
Which finding should the nurse expect in a client with Parkinson’s disease?
A. Muscle rigidity and tremors
B. Rapid movements and confusion
C. Hyperreflexia
D. Spastic paralysis
A. Muscle rigidity and tremors ✅
Rationale: Parkinson’s results from decreased dopamine, leading to tremors, rigidity, and bradykinesia.
A client reports drooping eyelids and difficulty swallowing that improves with rest. The nurse suspects:
A. Multiple sclerosis
B. Myasthenia gravis
C. Parkinson’s disease
D. ALS
B. Myasthenia gravis ✅
Rationale: MG is characterized by fatigueable muscle weakness, especially of ocular and facial muscles.
A client with ischemic stroke symptoms arrives at the ED 2 hours after onset. What is the priority nursing action?
A. Administer aspirin immediately.
B. Prepare for fibrinolytic therapy (tPA).
C. Encourage oral fluids.
D. Keep the client supine.
B. Prepare for fibrinolytic therapy (tPA). ✅
Rationale: Fibrinolytic therapy must be started within 3–4.5 hours to restore perfusion and reduce deficits.
Which mnemonic helps identify early signs of a stroke?
A. RACE
B. BEFAST
C. SAMPLE
D. AVPU
B. BEFAST ✅
Rationale: Balance, Eyes, Face, Arms, Speech, Time — act fast if symptoms appear.
A nurse is caring for a client taking diazepam. Which statement by the client indicates a need for further teaching?
A. “I’ll avoid driving until I know how this drug affects me.”
B. “I should not drink alcohol while taking this medication.”
C. “If I feel fine, I can stop taking it right away.”
D. “I’ll take it only as prescribed.”
C. “If I feel fine, I can stop taking it right away.” ✅
Rationale: Abrupt discontinuation can cause withdrawal symptoms and seizures; diazepam must be tapered gradually.
A nurse is reinforcing teaching for a client who has recently started an SSRI. Which adverse effect should the nurse instruct the client to report immediately?
A. Dry mouth
B. Weight gain
C. Increased suicidal thoughts
D. Mild headache
C. Increased suicidal thoughts ✅
Rationale: SSRIs can increase suicidal ideation, especially in young adults and early in therapy.
A nurse is caring for a client taking an SSRI who reports restlessness, sweating, and muscle rigidity. Which is the nurse’s priority action?
A. Document findings and monitor hourly.
B. Administer an antipyretic.
C. Notify the healthcare provider immediately.
D. Offer oral fluids.
C. Notify the healthcare provider immediately. ✅
Rationale: These are symptoms of serotonin syndrome, a life-threatening emergency requiring prompt intervention.
Which food selection indicates a client needs further instruction while taking phenelzine (an MAOI)?
A. Grilled chicken and rice
B. Fresh fruits and vegetables
C. Aged cheddar cheese and red wine
D. Baked fish with potatoes
C. Aged cheddar cheese and red wine ✅
Rationale: Tyramine-rich foods (aged cheese, wine, cured meats) can trigger hypertensive crisis.
A client taking tranylcypromine reports a pounding headache, palpitations, and stiff neck. What is the nurse’s priority action?
A. Administer antihypertensive medication as prescribed.
B. Offer a cool compress.
C. Reassure and monitor.
D. Encourage fluids.
A. Administer antihypertensive medication as prescribed. ✅
Rationale: These are signs of hypertensive crisis caused by MAOI and tyramine interaction—treat immediately.
A nurse provides discharge teaching to a client prescribed lithium. Which statement indicates correct understanding?
A. “I’ll take my lithium with food to reduce stomach upset.”
B. “I can double my dose if I miss one.”
C. “I’ll reduce salt intake to avoid swelling.”
D. “I’ll stop drinking fluids if I feel nauseated.”
A. “I’ll take my lithium with food to reduce stomach upset.” ✅
Rationale: Taking with food helps GI tolerance; lithium levels depend on stable hydration and sodium intake.
A client taking lithium reports excessive sweating after working outside. What is the nurse’s best response?
A. “That’s normal; lithium increases sweating.”
B. “Increase fluid and salt intake and notify your provider.”
C. “Take an extra lithium dose to replace what you lost.”
D. “Avoid all salt to prevent fluid retention.”
B. “Increase fluid and salt intake and notify your provider.” ✅
Rationale: Dehydration and sodium loss increase lithium levels, leading to toxicity.
A postoperative client receiving oxycodone reports pain rated 8/10 but has a respiratory rate of 8/min. What is the nurse’s priority action?
A. Administer the oxycodone as ordered.
B. Reassess pain in 30 minutes.
C. Hold the medication and notify the provider.
D. Encourage deep breathing exercises.
C. Hold the medication and notify the provider. ✅
Rationale: Respiratory depression is the primary risk; hold opioid if RR <12 and notify the provider.
A nurse is evaluating a client with Parkinson’s disease who takes carbidopa-levodopa. Which finding indicates the medication is effective?
A. Decreased tremors and improved mobility
B. Increased drooling and rigidity
C. Slower movement and more fatigue
D. Facial mask-like expression
A. Decreased tremors and improved mobility ✅
Rationale: Levodopa replenishes dopamine, reducing tremors and rigidity, improving movement.