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A client with major depressive disorder is prescribed lithium carbonate. Which finding should the RN report to the healthcare provider?
- A. Serum lithium level of 0.8 mEq/L
- B. Blood urea nitrogen (BUN) level of 16 mg/dL
- C. Serum sodium level of 138 mEq/L
- D. Urine output of 800 mL in 24 hours
Correct Answer: B
Rationale: The correct answer is B. Elevated BUN levels may indicate renal impairment, which is crucial to report for clients on lithium due to its potential kidney effects. Option A, a serum lithium level of 0.8 mEq/L, is within the therapeutic range for lithium and does not require immediate reporting. Option C, a serum sodium level of 138 mEq/L, is within the normal range and not directly related to lithium therapy. Option D, urine output of 800 mL in 24 hours, may indicate a need for further assessment but is not the most critical finding to report compared to potential renal impairment indicated by an elevated BUN level.
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A female client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most important for the nurse to take?
- A. Assure the client that the healthcare provider will see her today.
- B. Recommend that the client talk with a social worker.
- C. Ask the client to describe why she is being stalked.
- D. Offer the client a safe place to relax before interviewing her.
Correct Answer: D
Rationale: The most important action for the nurse to take in this scenario is to offer the client a safe place to relax before interviewing her. The client's disheveled appearance and foul body odor suggest she may be in distress or facing challenging circumstances. By providing her with a safe and comfortable environment to relax, the nurse can help alleviate some of her distress and establish trust. This approach is crucial as the client is already feeling scared due to being stalked, indicating underlying mental health concerns. Assuring the client of a healthcare provider visit (choice A) may not address her immediate need for safety and comfort. Recommending she talk with a social worker (choice B) may be beneficial later but does not address the immediate need for a safe space. Asking the client to describe why she is being stalked (choice C) is not appropriate as the priority is ensuring her safety and comfort first.
A client with a history of substance abuse is admitted to the hospital for treatment of a new illness. Which of the following is the most important to assess upon admission?
- A. History of recent drug use.
- B. Current employment status.
- C. Family history of mental illness.
- D. Recent weight changes.
Correct Answer: A
Rationale: Assessing the history of recent drug use is crucial when admitting a client with a history of substance abuse. Understanding recent drug use helps in managing potential withdrawal symptoms, preventing drug interactions with the new treatment, and ensuring appropriate care. Assessing current employment status (choice B) is important for social and financial support but is not as crucial as assessing recent drug use in this scenario. Family history of mental illness (choice C) and recent weight changes (choice D) are also important aspects of assessment but are not as immediate and critical as evaluating recent drug use in a client with a history of substance abuse.
A client in the emergency department presents with confusion, disorientation, and agitation after drinking alcohol. Which diagnostic test should the nurse anticipate to assess for potential complications?
- A. Complete blood count (CBC)
- B. Electrolyte panel
- C. Liver function tests
- D. Urinalysis
Correct Answer: B
Rationale: The correct answer is an electrolyte panel. When a client presents with confusion, disorientation, and agitation after drinking alcohol, it indicates potential complications such as electrolyte imbalances. Monitoring electrolyte levels is crucial in these cases to detect and address abnormalities that may result from alcohol intake. While a complete blood count (choice A) may provide some valuable information, it is not the primary test to assess for alcohol-related complications presenting with these symptoms. Liver function tests (choice C) are more specific for assessing liver damage due to chronic alcohol use rather than immediate complications. Urinalysis (choice D) may help detect some issues but is not the most appropriate initial test to assess for potential complications in this scenario.
A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse's station in a literally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?
- A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril).
- B. Offer the client a prescribed physical therapy hot pack for muscle spasms.
- C. Direct the client to occupational therapy to distract him from somatic complaints.
- D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.
Correct Answer: D
Rationale: The correct action for the nurse to take in this situation is to administer the prescribed anticholinergic benztropine (Cogentin) for dystonia. The client's symptoms of body contortion and feeling like a monster are indicative of acute dystonia, which can be a side effect of antipsychotic medications like risperidone. Benztropine can help alleviate these acute dystonic reactions. Choice A is incorrect because changing the antipsychotic medication at this point is not indicated. Choice B is not appropriate as the client's symptoms are likely due to acute dystonia rather than muscle spasms. Choice C is also not the best course of action as the client needs immediate intervention for the acute dystonic reaction.
The client is being educated by the healthcare provider about starting a prescribed abstinence therapy with disulfiram (Antabuse). What information should the client understand?
- A. Maintain complete abstinence from heroin or cocaine use.
- B. Stay alcohol-free for at least 12 hours before the first dose.
- C. Participate in monthly Alcoholics Anonymous meetings.
- D. Disclose to others that he is a substance abuser.
Correct Answer: B
Rationale: The correct answer is B. Before starting disulfiram therapy (Antabuse), the client must comprehend the need to remain alcohol-free for a minimum of 12 hours. This is crucial to prevent the unpleasant and potentially dangerous reactions that can occur with concurrent alcohol consumption while on disulfiram. Choices A, C, and D are incorrect because they do not directly relate to the specific requirement for alcohol abstinence before initiating disulfiram therapy.