Nokea
A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan?
- A. Eat a high-carbohydrate, low-fat, low-protein diet.
- B. Do not take any over-the-counter medication.
- C. Call the crisis hotline if feeling lonely.
- D. Avoid exposure to large crowds.
Correct Answer: B
Rationale: The most important information for the nurse to include in the client's discharge plan is to not take any over-the-counter medication. This is crucial because over-the-counter medications can potentially interact with the damaged liver and worsen the condition. Choices A, C, and D are not as critical in the context of liver damage from an acetaminophen overdose. While diet is important for overall health, specifically for liver damage, avoiding over-the-counter medications takes precedence. Calling the crisis hotline for loneliness and avoiding exposure to large crowds are important considerations but are not directly related to the client's liver damage from the acetaminophen overdose.
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In pediatric mental health, there is a lack of sufficient numbers of community-based resources and providers, resulting in long waiting lists for services. This has resulted in:
- A. Children of color and those in poor economic conditions being underserved
- B. Increased stress in the family unit
- C. Markedly increased funding
- D. Premature termination of services
Correct Answer: D
Rationale: The correct answer is D, 'Premature termination of services.' The lack of sufficient numbers of community-based resources and providers, along with long waiting lists, can lead to premature termination of services for children in need of mental health support. Choice A, 'Children of color and those in poor economic conditions being underserved,' is not directly related to the consequence mentioned in the question. Choice B, 'Increased stress in the family unit,' while a potential consequence, is not explicitly stated in the question as a direct result of the lack of resources. Choice C, 'Markedly increased funding,' is not a consequence but rather a potential solution to address the lack of resources.
A teenager who has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the nurse to include in the client plan of care?
- A. Implement behavior modification therapy.
- B. Initiate caloric and nutritional therapy.
- C. Evaluate the client for low self-esteem.
- D. Record daily weights and graph trends.
Correct Answer: B
Rationale: Initiating caloric and nutritional therapy is the most important intervention for this client due to the significant weight loss and presenting symptoms of hypotension, tachycardia, irregular menses, and hair loss. This intervention aims to address the physical effects of malnutrition and support the client's overall health. Behavior modification therapy (Choice A) may be beneficial in the long term to address underlying issues, but addressing the immediate nutritional needs is a priority. Evaluating the client for low self-esteem (Choice C) is important for holistic care but addressing the physical health concerns takes precedence. Recording daily weights and graphing trends (Choice D) is essential for monitoring progress but does not address the urgent need for nutritional support in this acute situation.
Pablo is a homeless adult who has no family connections. Pablo passed out on the street, and emergency medical services took him to the hospital where he expresses a wish to die. The physician recognizes evidence of substance use problems and mental health issues and recommends inpatient treatment for Pablo. What is the rationale for this treatment choice? Select all that apply.
- A. Intermittent supervision is available in inpatient settings.
- B. He requires stabilization of multiple symptoms.
- C. He has nutritional and self-care needs.
- D. Medication adherence will be mandated.
Correct Answer: A
Rationale: The correct answer is A. In inpatient settings, there is continuous supervision available, ensuring safety and comprehensive care for individuals like Pablo who may be at risk due to substance use problems, mental health issues, and expressing a wish to die. Choice B is incorrect because the need for stabilization of multiple symptoms alone is not the primary rationale for inpatient treatment. Choice C is incorrect as although self-care and nutritional needs are important, they do not solely justify inpatient treatment. Choice D is incorrect because while medication adherence can be monitored in inpatient settings, it is not the primary rationale for choosing inpatient treatment for Pablo in this scenario.
The RN is admitting a male client who takes lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately?
- A. Short-term memory loss.
- B. Five-pound weight gain.
- C. Decreased affect.
- D. Nausea and vomiting.
Correct Answer: D
Rationale: Nausea and vomiting are signs of potential lithium toxicity, which is a serious condition requiring immediate attention. These symptoms can indicate a dangerous level of lithium in the body that can lead to severe complications. Short-term memory loss (A), five-pound weight gain (B), and decreased affect (C) are important to monitor but are not as immediately concerning as symptoms of potential toxicity like nausea and vomiting.
After surgery, a male client with antisocial personality disorder frequently requests a specific nurse be assigned to his care and becomes belligerent when another nurse is assigned. What action should the charge nurse implement?
- A. Reassure the client that his request will be met whenever possible.
- B. Advise the client that assignments are not based on client requests.
- C. Ask the client to explain why he constantly requests the nurse.
- D. Encourage the client to verbalize his feelings about the nurse.
Correct Answer: B
Rationale: The correct action for the charge nurse is to advise the client that assignments are not based on client requests. Clients with antisocial personality disorder may attempt to manipulate situations to their advantage. By setting clear boundaries and explaining that assignments are not based on client preferences, the nurse helps prevent manipulation and maintains a professional approach to care. Reassuring the client about his requests (Choice A) may encourage the inappropriate behavior to continue. Asking the client to explain his requests (Choice C) may further fuel the manipulation by providing an opportunity for the client to justify his actions. Encouraging the client to verbalize feelings (Choice D) does not address the underlying issue of manipulating the assignment process and may inadvertently reinforce the behavior.