Nokea
A client with bipolar disorder receives Eskalith (lithium carbonate) bid. Which observation is associated with lithium toxicity?
- A. Hyporeflexia
- B. Akathesia
- C. Ataxia
- D. Petechiae
Correct Answer: C
Rationale: Ataxia , or impaired coordination, is a sign of lithium toxicity. Hyporeflexia is not typical. Akathesia is restlessness, often linked to antipsychotics. Petechiae indicate bleeding issues, not lithium toxicity.
You may also like to solve these questions
A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states 'I demand to be released now!' The appropriate response from the nurse is
- A. You cannot be released because you are still suicidal.
- B. You can be released only if you sign a no suicide contract.
- C. Let's discuss your decision to leave and then we can prepare you for discharge.
- D. You have a right to sign out as soon as we get the provider's discharge order.
- E. Cbe released because you are still suicidal.
- F. You can be released only if you sign a no suicide contract.
Correct Answer: C
Rationale: Clients voluntarily admitted to the hospital have a right to demand and obtain release. Discussing the decision initially allows an opportunity for other interventions.
An 85-year-old woman recovering from a fractured pelvis in a long-term care facility. The woman's activity order reads: ambulate with walker bid.
After the nurse implements the order, which of the following charting entries is BEST?
- A. Patient ambulated well with walker. States has no c/o stiffness or pain. Did not appear fatigued.'
- B. Ambulated without difficulty for 20 minutes. Vital signs remained stable. Color good.'
- C. Walked full length of hall with walker. No difficulty with balance. Using walker correctly.'
- D. Patient ambulated 60 feet independently with walker. Gait steady. Respirations 14 and unlabored.'
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) gives subjective information (2) gives judgments without objective information (3) information is not complete, contains some judgments without objective information (4) correct-gives objective information
The nurse is teaching testicular self-exam to a group of young men. Which information should be included in the instructions? Select all that apply.
- A. Perform the exam once a week.
- B. Palpate each testicle between the thumb and forefinger.
- C. Palpate the spermatic cord.
- D. Look in the mirror for dimpling.
- E. Testicles should be the same size.
- F. Both testicles should be at the same level.
Correct Answer: B,C
Rationale: Palpating the testicle and spermatic cord detects lumps or abnormalities during testicular self-exam. Monthly (not weekly) exams are recommended, dimpling is for breast exams, and testicles may differ slightly in size and level.
An 18-year-old client with anorexia nervosa is admitted to the hospital.
In planning to care for the client, the nurse would expect the client to
- A. view her appearance as 'skinny.'
- B. be hypoactive and withdrawn.
- C. want to talk about and plan her meals.
- D. have a close relationship with her mother.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to anorexia. (1) usually view their appearance as fat (2) inaccurate for client with anorexia nervosa (3) correct-display a marked preoccupation with food (4) inaccurate for client with anorexia nervosa
A wet-to-dry dressing is ordered for a client who has a decubitus ulcer. Which technique is appropriate?
- A. Irrigate the wound and then apply a dry dressing and cover with a wet compress.
- B. Apply a wet dressing for two hours followed by a dry dressing for two hours.
- C. Apply a wet dressing, and cover with a dry dressing.
- D. Apply a wet dressing above the wound and a dry dressing below the wound.
Correct Answer: C
Rationale: Wet-to-dry dressings involve a moist gauze applied to the wound, covered with dry gauze, to debride tissue as it dries. Other techniques are incorrect.