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A male patient calls to tell the nurse that his monthly lithium level is 1.7 mEq/L. Which nursing intervention will the nurse implement initially?
- A. Reinforce that the level is above the therapeutic range.
- B. Instruct the patient to hold the next dose of medication and contact the prescriber.
- C. Advise the patient to go to the hospital emergency room immediately.
- D. Inform the patient about the possibility of seizures and appropriate precautions.
Correct Answer: B
Rationale: A lithium level of 1.7 mEq/L is above the therapeutic range, indicating a potential risk of toxicity. The initial nursing intervention should be to instruct the patient to hold the next dose of medication and promptly contact the prescriber for further guidance and management. This action aims to prevent adverse effects and ensure the patient's safety by addressing the elevated lithium level appropriately.
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Which response demonstrates accurate information that should be discussed with the female patient diagnosed with bipolar disorder and her support system? Select the incorrect one.
- A. Remember that alcohol and caffeine can trigger a relapse of your symptoms.
- B. Due to the risk of a manic episode, antidepressant therapy is never used with bipolar disorder.
- C. It's critical to inform your healthcare provider immediately if you are experiencing sleep disturbances.
- D. Is your family prepared to be actively involved in helping manage this disorder?
Correct Answer: B
Rationale: In managing bipolar disorder, it is vital to educate the patient and their support system about triggers like alcohol and caffeine, the significance of good sleep, and the need for family involvement. However, the statement in choice B is incorrect. While antidepressants need to be carefully monitored in bipolar disorder, they can be used in conjunction with mood stabilizers to manage depression in some cases.
Which assessment question asked by the nurse demonstrates an understanding of comorbid mental health conditions associated with major depressive disorder? Select one that doesn't apply.
- A. Do rules apply to you?
- B. What do you do to manage anxiety?
- C. Do you have a history of disordered eating?
- D. Do you think that you drink too much?
Correct Answer: A
Rationale: Questions about anxiety management, disordered eating, and alcohol use are relevant to identifying comorbid conditions with major depressive disorder, but the question 'Do rules apply to you?' does not directly address common comorbid mental health conditions associated with major depressive disorder.
Which characteristic presents the greatest risk for injury to others in a patient diagnosed with schizophrenia?
- A. Depersonalization
- B. Pressured speech
- C. Negative symptoms
- D. Paranoia
Correct Answer: D
Rationale: Paranoia in patients with schizophrenia can lead to aggressive behaviors, including violence, which poses a significant risk of injury to others. Individuals experiencing paranoia may perceive others as threats and act defensively or aggressively in response, increasing the likelihood of harm to those around them.
James is a 42-year-old patient with schizophrenia. He approaches you as you arrive for the day shift and anxiously reports, 'Last night, demons came to my room and tried to rape me.' Which response would be most therapeutic?
- A. There are no such things as demons. What you saw were hallucinations.
- B. It is not possible for anyone to enter your room at night. You are safe here.
- C. You seem very upset. Please tell me more about what you experienced last night.
- D. That must have been very frightening, but we'll check on you at night and you'll be safe.
Correct Answer: C
Rationale: Response C is the most therapeutic as it shows empathy and encourages the patient to express their feelings and share more about their experience. By actively listening and inviting the patient to talk, the nurse creates a supportive environment that can help the patient feel heard and understood, which is essential in building trust and rapport in therapeutic communication with individuals experiencing schizophrenia.
Which therapeutic communication statement might a psychiatric-mental health registered nurse use when a patient's nursing diagnosis is altered thought processes?
- A. I know you say you hear voices, but I cannot hear them.
- B. Stop listening to the voices, they are NOT real.
- C. You say you hear voices, what are they telling you?
- D. Please tell the voices to leave you alone for now.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.