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A client has been on lithium carbonate therapy for 7 days. Which of the following findings would be most important to report to the health care provider?
- A. Diarrhea, vomiting, and mild tremor
- B. Dry mouth and mild thirst
- C. Hyperactivity and auditory hallucinations
- D. Lithium level of 1.3 mEq/L (1.3 mmol/L)
Correct Answer: A
Rationale: Diarrhea, vomiting, and tremor (A) suggest lithium toxicity, requiring immediate reporting. Dry mouth (B) is common, hallucinations (C) are unrelated, and a lithium level of 1.3 (D) is within therapeutic range.
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An 87-year-old client has been admitted to the hospital with signs and symptoms of a urinary tract infection along with agitation, confusion, and disorientation to time and place. What is the most important nursing action?
- A. Encouraging frequent fluid intake
- B. Keeping the bed elevated and side rails raised
- C. Providing one-on-one supervision
- D. Turning the lights off in the client's room
Correct Answer: C
Rationale: One-on-one supervision (C) ensures safety for a confused, agitated client at risk for falls or harm. Fluids (A), side rails (B), and dim lights (D) are secondary or inappropriate.
The nurse preparing an educational seminar on sexually transmitted infections for female college students should advise that which 2 infections are leading causes of pelvic inflammatory disease and infertility?
- A. Genital herpes and HIV
- B. Gonorrhea and chlamydia
- C. Human papillomavirus and syphilis
- D. Yeast and trichomoniasis
Correct Answer: B
Rationale: Gonorrhea and chlamydia (B) are bacterial infections that commonly cause pelvic inflammatory disease and infertility if untreated. Other options are less associated with these outcomes.
The nurse is reinforcing teaching for a client with suspected Cushing syndrome who has a 24-hour urine specimen. Which of the following information should the nurse reinforce? Select all that apply.
- A. An indwelling urinary catheter will be inserted for this test and your urine will be collected in an attached drainage bag.
- B. Discard your first void in the toilet and then record the start time of the urine collection so that the start time coincides with an empty bladder.
- C. Keep the collection container in the refrigerator or a cooled ice chest when it is not in use.
- D. Only daytime urine should be collected in the container because cortisol levels are higher in the morning.
- E. You will be given an opaque plastic container to collect your urine to protect it from light.
Correct Answer: B,C
Rationale: Discarding the first void and recording the start time (B) ensures accurate collection, and refrigerating the container (C) preserves the sample. Catheters (A) are not needed, all urine is collected (D is incorrect), and light protection (E) is unnecessary.
The nurse has completed teaching the client about his low-sodium, low-fat diet. Which menu, if selected by the client, would indicate to the nurse that the client understands his diet?
- A. Mashed potatoes, spinach, and meatloaf
- B. Swordfish with Hollandaise sauce, carrots, and rice pilaf
- C. Baked chicken, wild rice, and broccoli
- D. Roast beef with gravy, baked potato with sour cream, and creamed peas
Correct Answer: C
Rationale: Baked chicken, wild rice, and broccoli are low in sodium and fat, aligning with the diet. Meatloaf, Hollandaise, and gravy/sour cream/creamed peas are high in sodium or fat.
The nurse is caring for an older adult client who is confused and has a high risk for falls. The client is incontinent of urine and frequently attempts to get out of bed unassisted to use the restroom. Which nursing interventions are appropriate when caring for this client? Select all that apply.
- A. Ensuring bed alarm remains activated
- B. Initiating an hourly rounding schedule
- C. Inserting an indwelling urinary catheter
- D. Moving client to a room close to the nurses' station
- E. Raising all side rails of the client's bed
Correct Answer: A,B,D
Rationale: Bed alarms (A), hourly rounding (B), and proximity to the nurses' station (D) enhance safety and monitoring. Catheters (C) increase infection risk and are not first-line, and raising all side rails (E) is a restraint and unsafe.