Nokea
A client has been taking lithium for several years with good symptom control. The client presents in the emergency department with blurred vision, tinnitus, and severe diarrhea. Which lithium level should the nurse correlate with these symptoms?
- A. 3.7
- B. 1.7
- C. 2.6
- D. 1.3
Correct Answer: B
Rationale: Symptoms such as blurred vision, tinnitus, and severe diarrhea are indicative of lithium toxicity. A lithium level of 1.7 is within the toxic range. When clients present with these symptoms, it is crucial for the nurse to correlate them with elevated lithium levels to ensure timely intervention and prevent further complications.
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A client is diagnosed with somatic symptom disorder. Which question will help the nurse develop nursing diagnoses for this client's plan of care?
- A. Are you satisfied with your appearance?
- B. Do you take medication for anxiety as prescribed?
- C. When did you last feel detached from your environment?
- D. How long have you had these memory problems?
Correct Answer: B
Rationale: In clients with somatic symptom disorder, it is crucial to assess their adherence to medication for anxiety as prescribed. This question helps the nurse understand the client's treatment compliance, which can impact the development of nursing diagnoses and the overall plan of care. Monitoring medication adherence is essential in managing the client's symptoms and improving outcomes.
After 1 week of continuous mental confusion, an elderly African American client is
admitted with a preliminary diagnosis of a neurocognitive disorder due to dementia.
Which statement would cause the nurse to question this diagnosis?
- A. There has been no triiodothyronine or thyroxine level evaluation ordered
- B. Neurocognitive disorders do not typically occur in African American clients
- C. The symptoms presented are more indicative of parkinsonism
- D. Dementia does not develop suddenly
Correct Answer: D
Rationale:
While auditing care plans for clients with eating disorders, the nurse realizes that a nursing diagnosis appropriate for a client with anorexia nervosa as well as for a client with bulimia nervosa is
- A. Risk for imbalanced body temperature
- B. Ineffective denial
- C. Chronic low self-esteem
- D. Adult failure to thrive
Correct Answer: C
Rationale: Chronic low self-esteem is a nursing diagnosis that can be applicable to clients with both anorexia nervosa and bulimia nervosa. These eating disorders are often associated with distorted body image, feelings of inadequacy, and low self-esteem. Clients with these conditions may engage in harmful behaviors related to their self-image, making chronic low self-esteem a relevant nursing diagnosis for them.
Before discharge from the chemical dependency unit, clients are introduced to different community resources. Which of the following resources would be best for a teenage client, who has been abusing over-the-counter sedatives and is ready for discharge in two days?
- A. Detoxification center
- B. Home care
- C. Assertive community team
- D. Twelve-step recovery group
Correct Answer: A
Rationale: For a teenage client who has been abusing over-the-counter sedatives and is ready for discharge in two days, the best resource would be a detoxification center. This specialized facility can provide the necessary medical and psychological support to safely manage the withdrawal symptoms associated with substance abuse. It is crucial to ensure a safe and supervised detox process for the client's well-being and successful recovery.
A nursing instructor is teaching a group of students about intimate partner violence. Which response by the students indicates no further teaching is needed?
- A. Alaska Native women report the highest rate of intimate partner violence.
- B. Caucasian women report the lowest rate of intimate partner violence.
- C. African American women report the highest rate of intimate partner violence.
- D. Asian women report the lowest rate of intimate partner violence.
Correct Answer: A
Rationale: The correct answer is A. Alaska Native women do report the highest rate of intimate partner violence. This statistic is important for healthcare professionals to be aware of to provide culturally sensitive care and interventions. Choices B, C, and D are incorrect statements. While it is essential to understand disparities in intimate partner violence rates among different populations, in this context, the focus is on recognizing the accurate information provided about Alaska Native women.