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Questions 163

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Question 1 of 5

The physician has prescribed Elavil(amitriptyline) for a client with depression. The nurse should continue to monitor the client's mood because the maximal effects of tricyclic antidepressant medication does not occur for:

Correct Answer: C

Rationale: Tricyclic antidepressants like amitriptyline take 2-4 weeks to reach maximal therapeutic effect.

Choices A and B are too short, and D is excessively long.

Question 2 of 5

An 80-year-old woman is having difficulty sleeping. Which nursing action is most appropriate initially?

Correct Answer: C

Rationale: Avoiding daytime naps improves nighttime sleep hygiene, a non-pharmacologic initial approach suitable for an elderly client.

Question 3 of 5

The nurse has just received the shift report. Which one of the following clients should be seen first?

Correct Answer: D

Rationale: Answer D is correct. There is nothing in answer A that indicates the client is unstable. Answer B is a good choice, but the client three days post-fracture may have a slight temperature, so he should be seen second. Answer C is also a good choice, but if the infant with dehydration is stable, the 8-week-old with respiratory distress (sub-sternal retractions and low oxygen saturation) is the most critical and should be seen first.

Question 4 of 5

A client is in suspected shock state from major trauma. Which of the following parameters indicate the adequacy of peripheral perfusion? Select all that apply.

Correct Answer: B,E

Rationale: Capillary refill time and skin color/temperature directly assess peripheral perfusion in shock. Apical pulse , lung sounds , and pupillary response evaluate other aspects.

Question 5 of 5

The nurse is caring for 2 children who have had surgical repair of congenital heart defects. For which defect is it a priority to assess for findings of heart conduction disturbance?

Correct Answer: D

Rationale: Ventricular septal defect. Surgical repair involves manipulation of the ventricular septum, increasing the risk of conduction disturbances.

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