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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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Maggie, a child in protective custody, is found to have an imaginary friend, Holly. Her foster family shares this information with the nurse. The nurse teaches the family members about children who have suffered trauma and knows her teaching was effective when the foster mother states:
- A. I understand that imaginary friends are abnormal.
- B. I understand that imaginary friends are a maladaptive behavior.
- C. I understand that imaginary friends are a coping mechanism.
- D. I understand that we should tell the child that imaginary friends are unacceptable.
Correct Answer: C
Rationale: Imaginary friends can serve as a coping mechanism for children, especially those who have experienced trauma. They can provide comfort and a sense of control in challenging situations. Acknowledging and supporting the child's imaginary friend can be beneficial in their emotional healing and development.
The mental health team is determining treatment options for a male patient experiencing psychotic symptoms. Which question shouldn't the team answer to determine whether a community outpatient or inpatient setting is most appropriate?
- A. Is the patient expressing suicidal thoughts?
- B. Does the patient have intact judgment and insight into his situation?
- C. Does the patient have experiences with either community or inpatient mental healthcare facilities?
- D. Does the patient require a therapeutic environment to support the management of psychotic symptoms?
Correct Answer: C
Rationale: Assessing suicidal thoughts, judgment, insight, and the need for a therapeutic environment are crucial factors in determining the appropriate treatment setting for a patient experiencing psychotic symptoms. Past experiences with mental healthcare facilities do not play a direct role in deciding between a community outpatient or inpatient setting.
In a client's history, a significant indicator suggesting marginal coping skills and the need for careful risk assessment for violence is a history of
- A. childhood trauma.
- B. family involvement.
- C. academic problems.
- D. chemical dependence.
Correct Answer: D
Rationale: A history of chemical dependence is a critical factor indicating marginal coping skills and the need for assessing the risk of violence. Substance abuse can impair judgment, increase impulsivity, and escalate the likelihood of violent behavior. It is essential to thoroughly evaluate and address substance abuse issues in clients to enhance treatment outcomes and ensure safety.
Why is it important to establish a contract with a client with an eating disorder at the beginning of treatment?
- A. The client and healthcare provider form a partnership that is challenging for the family to disrupt.
- B. A collaborative approach to treatment planning ensures that both physical and emotional needs will be addressed.
- C. Involving the client in decision-making enhances the feeling of control and fosters cooperation.
- D. Permission for refeeding is crucial as it can have adverse effects.
Correct Answer: C
Rationale: Establishing a contract with a client with an eating disorder at the start of treatment is crucial to involve the client in decision-making processes. By engaging the client in decision-making, it enhances their sense of control over their treatment, which can lead to increased cooperation and better treatment outcomes. This collaborative approach empowers the client and fosters a therapeutic alliance between the client and the healthcare provider, rather than excluding the family or causing disruptions. It focuses on addressing both the physical and emotional needs of the client, ensuring a comprehensive treatment plan.
How does emotional trauma typically affect individuals physically?
- A. Emotional trauma is a distinct category and unrelated to physical symptoms.
- B. Physical manifestations of emotional trauma are usually temporary.
- C. Emotional trauma is often manifested as physical symptoms.
- D. Patients are more aware of physical problems caused by trauma.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.