Nokea
A client is placed on lithium therapy for her manic-depressive illness. When monitoring the client, the nurse assesses the laboratory blood values. Toxicity may occur with lithium therapy when the blood level is above:
- A. 1.0 mEq/L
- B. 2.2 mEq/L
- C. 0.03 mEq/L
- D. 1.5 mEq/L
Correct Answer: D
Rationale: This value is the level at which most clients are maintained, and toxicity may occur if the level increases. The client should be monitored closely for symptoms, because some clients become toxic even at this level.
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The nurse is caring for a client with a diagnosis of postpartum endometritis. Which vital sign change is most characteristic?
- A. Fever
- B. Tachycardia
- C. Hypotension
- D. All of the above
Correct Answer: A
Rationale: Fever is the most characteristic vital sign change in postpartum endometritis reflecting the underlying uterine infection. Tachycardia and hypotension occur only in severe cases.
Following TURP, which of the following instructions would be appropriate to prevent or alleviate anxiety concerning the client's sexual functioning?
- A. You may resumption sexual intercourse in 2 weeks.'
- B. Many men experience impotence following TURP.'
- C. A transurethral resection does not usually cause impotence.'
- D. Check with your doctor about resuming sexual activity.'
Correct Answer: C
Rationale: Although the client may experience retrograde ejaculation, it will not limit his ability to engage in sexual intercourse.
A male client has burns over 90% of his body after an automobile accident resulting in a fire. He was trapped inside the auto and pulled out by a bystander. After several months in the hospital and over 20 surgeries, discharge planning has begun. Throughout his hospitalization the nursing staff has been aware of psychological changes the client faces after burns over a large portion of his body resulting in disfigurement. The nursing staff can best foster the client's self-esteem by:
- A. Adhering to a strict schedule of diet, exercise, and wound care
- B. Allowing him to go to physical therapy for whirlpool treatment when other clients were not in physical therapy
- C. Following a standardized plan of care for burn clients formulated by a world-renowned burn center
- D. Allowing him to plan, assist in, and perform his own care whenever possible
Correct Answer: D
Rationale: A regimented schedule, allowing no flexibility, will not foster the client's self-esteem. Isolating the client may only enhance his feelings of social isolation due to his disfigurement. Standardized care plans must be personalized and adapted to each client's situation. Allowing the client control over his care will foster his self-esteem and prepare him for life outside of the hospital.
The nurse is caring for a client with a diagnosis of abruptio placenta. Which nursing intervention is most appropriate?
- A. Monitor fetal heart tones
- B. Administer oxygen at 2 liters per minute
- C. Place the client in Trendelenburg position
- D. Increase IV fluid rate
Correct Answer: A
Rationale: Abruptio placenta can cause fetal hypoxia making monitoring fetal heart tones the most appropriate intervention to assess fetal well-being. Oxygen Trendelenburg and fluids are secondary based on clinical findings.
The nurse is caring for a client with a diagnosis of gestational trophoblastic disease. Which laboratory value is most likely to be elevated?
- A. Human chorionic gonadotropin (hCG)
- B. Alpha-fetoprotein (AFP)
- C. Estriol
- D. Progesterone
Correct Answer: A
Rationale: Gestational trophoblastic disease (e.g. molar pregnancy) causes markedly elevated hCG levels due to abnormal trophoblastic tissue growth. AFP estriol and progesterone are not typically elevated in this condition.