99.

The nurse recognizes which of the following as a positive response to

fluoxetine HC (Prozac)?
1.
2.
3.
4.

The
The
The
The

nurse notes hand tremors and leg twitching.

client states that he is able to sleep for longer periods of time.
client has an increased energy level and participates in unit activities.
nurse observes that the client is hypervigilant and scans the environment.

Strategy: Think about each answer choice.

(1) can be side effect of the medication
(2) not an effect of Prozac, can actually inhibit sleep; is useful with clients who
experience increased sleeping and psychomotor retardation and lethargy
(3) correctfluoxetine HC (Prozac) is an energizing antidepressant; as client begins
to demonstrate a positive response, s/he has an increased energy level, is able to
participate more in milieu
(4) can be side effect of medication
100. The nurse is supervising the staff caring for four clients receiving blood
transfusions. Which of the four clients should the nurse see FIRST?
1.
2.
3.
4.

A
A
A
A

client
client
client
client

complaining of a headache.
vomiting.
complaining of itching.
with neck vein distention.

Strategy: Determine the least stable client.

(1) febrile reaction, symptoms include fever, chills, nausea, headache; treatment is
to stop blood and administer aspirin
(2) correcthemolytic reaction, most dangerous type of transfusion reaction,
symptoms include nausea, vomiting, pain in lower back, hematuria; treatment is to
stop blood, obtain urine specimen, maintain blood volume and renal perfusion
(3) allergic reaction, symptoms include urticaria, pruritus, fever; treatment is to stop
blood, give Benadryl, and administer oxygen
(4) circulatory overload, treatment is to stop blood, position in an upright position,
administer oxygen
101. The nurse is planning care for a client on bedrest. To promote evening
rest and sleep for this client, it is MOST important for the nurse to
1.
2.
3.
4.

provide privacy.
give back rubs at hs.
assist with a bath every day.
encourage daytime activities.

Strategy: Answers are implementations. Determine the outcome of each

answer choice. Is it desired?
(1) excessive privacy can limit sensory input
(2) will help client to relax, but is not most important
(3) should encourage client to do as much of his care as he can to maintain
independence
(4) correctprovides relief from tension, ensures client naps less during the day,
helps client to relax