Author Question: Admission data for a newly admitted client who is severely depressed reveal he has lost 20 pounds ... (Read 118 times)

NguyenJ · **on:** Jul 19, 2018

Admission data for a newly admitted client who is severely depressed reveal he has lost 20 pounds
over the past month, has chronic low self-esteem, and has both the intent and a plan for committing
suicide.

He has been taking a selective serotonin reuptake inhibitor for 1 week without remission of
symptoms. The priority nursing diagnosis is
a. imbalanced nutrition: less than body requirements.
b. chronic low self-esteem.
c. risk for suicide.
d. ineffective protection.

Question 2

A nurse is caring for four clients who are receiving clozapine, lithium, fluoxetine, and venlafaxine,
respectively.

In which client should the nurse be most alert for alterations in cardiac or cerebral
electrical conductivity and fluid and electrolyte imbalance?
a. The client receiving lithium (Lithobid)
b. The client receiving clozapine (Clozaril)
c. The client receiving fluoxetine (Prozac)
d. The client receiving venlafaxine (Effexor)

rleezy04 · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

ANS: C
Risk for suicide is the priority diagnosis when the client has both suicidal ideation and has
developed a plan to carry out the suicidal intent. Imbalanced nutrition and chronic low self-esteem
are viable nursing diagnoses, but these problems do not affect client safety as urgently as would a
suicide attempt. Ineffective protection would be of greater concern if the client were taking
risperidone or an immune suppressant drug.

Answer to Question 2

ANS: A
Lithium is known to alter electrical conductivity, producing cardiac dysrhythmias, tremor,
convulsions, polyuria, edema, and other symptoms of fluid and electrolyte imbalance. Option B:
Clients receiving clozapine should be monitored for agranulocytosis. Option C: Clients receiving
fluoxetine should be monitored for acetylcholine block. Option D: Clients receiving venlafaxine
should be monitored for heightened feelings of anxiety.