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. Sit up comfortably in the bed is incorrect; the client should be in an upright position, which can be done while sitting up comfortably, but it’s essential to emphasize a more upright posture for optimal administration.
B. Tilt the head slightly to the side is correct; this position helps facilitate the delivery of the medication into the nasal passages.
C. Insert the tip of the nose piece into one nostril is correct; proper insertion ensures effective delivery of the medication.
D. Hold the breath for a few seconds after administering the spray is correct; this allows the medication to be absorbed more effectively.
E. Blow the nose 1 minute after administering the spray is incorrect; clients should avoid blowing their nose immediately after use to allow for proper absorption of the medication.
Correct Answer is B
Explanation
A. Administer the insulin to the client is incorrect as the nurse should first verify the dosage for safety before administration.
B. Check the dosage with another nurse is correct because double-checking the insulin dosage with another licensed nurse is a critical safety step to prevent medication errors.
C. Check the client's blood sugar again is incorrect; while monitoring blood sugar is important, it is not the immediate next action after preparing the insulin.
D. Ensure a meal tray is available is incorrect; although the client should have a meal ready after insulin administration, the priority action before administering the medication is to confirm the dosage.