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A client prescribed lithium carbonate for the treatment of bipolar disorder has a medication blood level of 1.6 mEq/L (1.6 mmol/L). Which assessment question should the nurse ask to determine whether the client is experiencing signs of lithium toxicity associated with this level?
- A. Do you hear ringing in your ears?
- B. Have you noted that your vision is blurred?
- C. Have you fallen recently because you are dizzy?
- D. Have you been experiencing any nausea, vomiting, or diarrhea?
Correct Answer: D
Rationale: Normal lithium levels are between 0.8 to 1.2 mEq/L (0.8 to 1.2 mmol/L). One of the most common early signs of lower level lithium toxicity is gastrointestinal (GI) disturbances such as nausea, vomiting, or diarrhea. The assessment questions in options 1, 2, and 3 are related to the findings in lithium toxicity at higher levels.
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A child is admitted to the hospital with a diagnosis of rheumatic fever. The nurse reviews the blood laboratory findings, knowing that which finding will confirm the likelihood of this disorder?
- A. Increased leukocyte count
- B. Decreased hemoglobin count
- C. Increased antistreptolysin-O (ASO titer)
- D. Decreased erythrocyte sedimentation rate
Correct Answer: C
Rationale: Children suspected of having rheumatic fever are tested for streptococcal antibodies. The most reliable and best standardized test to confirm the diagnosis is the ASO titer. An elevated level indicates the presence of rheumatic fever. The remaining options are unrelated to diagnosing rheumatic fever. Additionally, an increased leukocyte count indicates the presence of infection but is not specific in confirming a particular diagnosis.
A client diagnosed with diabetes mellitus is at 36 weeks' gestation. The client has had weekly reactive nonstress tests for the last 3 weeks. This week, the nonstress test was nonreactive after 40 minutes. Based on these results, the nurse should prepare the client for which intervention?
- A. A contraction stress test
- B. Immediate induction of labor
- C. Hospitalization with continuous fetal monitoring
- D. A return appointment in 2 days to repeat the nonstress test
Correct Answer: A
Rationale: A nonreactive nonstress test after 40 minutes indicates that the fetus did not show the expected heart rate accelerations, which may suggest fetal compromise, particularly in a high-risk pregnancy such as one with diabetes mellitus. The next step is typically a contraction stress test to further assess fetal well-being by evaluating the fetal heart rate response to uterine contractions. Immediate induction or hospitalization may be premature without further evaluation, and repeating the nonstress test in 2 days delays necessary assessment.
A client has had a nasointestinal (NI) tube in place for 24 hours. Which assessment finding indicates that the tube is properly located in the intestine?
- A. Bowel sounds are absent.
- B. The client denies being nauseous.
- C. Aspirate from the tube has a pH of 7.
- D. The abdominal x-ray indicates that the end of the tube is above the pylorus.
Correct Answer: C
Rationale: The nasogastric (NG) or NI tube is used to decompress the intestine and correct a bowel obstruction. Nausea should subside as decompression is accomplished. The pH of the gastric fluid is acidic, and the pH of the intestinal fluid is alkaline (7 or higher). Although bowel sounds will be abnormal in the presence of obstruction, the presence or absence of bowel sounds is not associated with the location of the tube. The end of the tube should be located in the intestine (below the pylorus). Location of the tube can also be determined by radiographs.
A client has a total serum calcium level of 7.5 mg/dL (1.88 mmol/L). Which clinical manifestations should the nurse expect to note on assessment of the client? Select all that apply.
- A. Constipation
- B. Muscle twitches
- C. Negative Chvostek's sign
- D. Positive Trousseau's sign
- E. Hyperactive deep tendon reflexes
- F. Prolonged ST interval on electrocardiogram (ECG)
Correct Answer: B,D,E,F
Rationale: Hypocalcemia is a total serum calcium level less than 9 mg/dL (2.25 mmol/L). Clinical manifestations include muscle twitches, hyperactive deep tendon reflexes, positive Trousseau's sign, and prolonged ST interval on ECG. Negative Chvostek's sign and constipation are not associated with hypocalcemia.
A client has not ingested any food or liquids for 4 hours after two episodes of nausea and vomiting. What will the nurse offer the client initially now that she or he is no longer nauseated?
- A. Toast
- B. Gelatin
- C. Dry cereal
- D. Ginger ale
Correct Answer: D
Rationale: Clear liquids are best tolerated first after episodes of nausea and vomiting. If the client tolerates sips (20 to 30 mL at a time) of clear liquids, such as water or ginger ale (with the carbonation removed if better tolerated), then the amounts may be increased and gelatin, tea, and broth may be added. Once these are tolerated, solid foods such as toast, cereal, chicken, and other easily digested foods may be tried.