The nurse is caring for a client taking fluoxetine for depression. Which assessment findings indicate that the medication is effective(Select all that apply.)
Improved sleep
Decreased anxiety
Reduced appetite
Weight loss
Correct Answer : A,B,E
A. Improved sleep is correct; an effective antidepressant can help normalize sleep patterns, which is a positive indicator of treatment efficacy.
B. Decreased anxiety is correct; fluoxetine is also effective in treating anxiety symptoms, so a reduction indicates the medication is working.
C. Reduced appetite is incorrect; while some individuals may experience appetite changes, a reduced appetite is not an indicator of effectiveness and could indicate a side effect.
D. Weight loss is incorrect; while weight loss can occur, it is not a definitive measure of the effectiveness of fluoxetine and can also signify side effects.
E. Interest in physical activity is correct; an increase in motivation and engagement in activities is a strong indicator of improvement in depressive symptoms.
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Correct Answer is ["B","C","D"]
Explanation
A. Sitting up comfortably in bed is not ideal for nasal spray administration; the client should be in an upright position, possibly sitting on the edge of a chair.
B. Tilting the head slightly to the side is correct; this position helps the medication to be delivered effectively to the nasal passages.
C. Inserting the tip of the nose piece into one nostril is correct; this ensures that the medication is delivered directly into the nasal cavity.
D. Holding the breath for a few seconds after administering the spray is correct; this allows for better absorption of the medication in the nasal mucosa.
E. Blowing the nose 1 minute after administering the spray is incorrect; the client should avoid blowing their nose for at least a few minutes after administration to allow the medication to be absorbed effectively.
Correct Answer is ["A","B"]
Explanation
A. The client's skin and eyes are visibly jaundiced is correct because jaundice indicates a buildup of bilirubin in the blood, which is a sign of liver dysfunction.
B. The client's AST and ALT levels are elevated is correct because elevated levels of these liver enzymes indicate hepatocellular injury, which is consistent with liver damage due to acetaminophen overdose.
C. The client's temperature is 102.5° F (39.2° C) is incorrect; while a fever can occur in various conditions, it is not specific for liver damage in this context.
D. The client has an elevated red blood cell count is incorrect; elevated red blood cell counts are not indicative of liver damage and may be related to other factors.
E. The client's eyes are sensitive to light is incorrect; photophobia is not a direct indicator of liver damage and is more related to other conditions.