A client begins taking an antidepressant drug during the second day of hospitalization. Which assessment is most important for the nurse to include in this client's plan of care while the client is taking the antidepressant?

Correct Answer: B

Rationale: Corrected Rationale: Monitoring the client's mood is essential when starting an antidepressant to assess for any changes or adverse effects related to the medication. Changes in mood can indicate the effectiveness of the antidepressant or potential side effects. Assessing appetite (Choice A) is important but not as crucial as monitoring mood in this context. Withdrawal symptoms (Choice C) are more relevant when discontinuing antidepressants rather than starting them. Energy level (Choice D) can be influenced by various factors and may not directly reflect the client's response to the antidepressant.

Correct Answer: D

Rationale: In this scenario, option D is the correct course of action. Catheterizing with an indwelling catheter and inflating the balloon if the residual volume is greater than 100 mL is appropriate for a resident with a distended bladder due to Benign Prostatic Hypertrophy. Option A is incorrect because standing the client to void and running tap water before catheterization could lead to urinary retention and exacerbate the distended bladder. Option B is incorrect as straight catheterization alone may not adequately address the issue of a distended bladder and clamping the catheter based on residual volume alone may not be appropriate. Option C is also incorrect as catheterizing the resident every 2 hours without addressing the underlying cause or providing immediate relief is not the most effective approach. In this educational context, it is important to understand the rationale behind interventions for managing urinary retention in patients with Benign Prostatic Hypertrophy to prevent complications such as urinary stasis, infection, and renal damage. The correct approach involves catheterizing with an indwelling catheter to provide continuous drainage and monitoring of residual volume to ensure appropriate bladder emptying.

Correct Answer: C

Rationale: Observing the lips and mucous membranes provides a reliable indicator of cyanosis in clients with dark skin tones. Choice A is incorrect because cyanosis can be assessed in clients with dark skin by observing other body areas. Choice B is incorrect as blanching the soles of the feet is not a relevant method for assessing cyanosis. Choice D is incorrect as cyanosis is not typically seen in the sclera in clients with dark skin.

Correct Answer: A

Rationale: Regular monitoring of blood glucose levels is crucial in managing diabetes and preventing complications. This allows the client and healthcare team to make timely adjustments to the treatment plan. While maintaining a low-fat diet, exercising regularly, and taking medication as prescribed are all important aspects of diabetes management, monitoring blood glucose levels takes precedence as it provides real-time information about the client's condition and helps prevent acute complications.

Correct Answer: C

Rationale: When a client receiving a blood transfusion reports chills and back pain, it indicates a possible transfusion reaction. The nurse's priority action is to stop the transfusion immediately. Continuing the transfusion at a slower rate (Choice A) can exacerbate the reaction. Administering an antipyretic (Choice B) may help with fever but does not address the underlying issue of a transfusion reaction. Notifying the healthcare provider (Choice D) is important but should not delay the immediate action of stopping the transfusion to ensure the client's safety.