Nokea
A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?
- A. Prepare for gastric lavage due to an extremely elevated lithium level.
- B. Administer the morning dose of lithium.
- C. Check the client's medication record to assess whether the client has been refusing her lithium.
- D. Hold the medication and assess for early manifestations of toxicity.
Correct Answer: B
Rationale: A lithium level of 1.0 mEq/L is within the therapeutic range (0.6-1.2 mEq/L).
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A nurse is caring for an adolescent female who has an eating disorder. The client is 162.6 cm (64 in) tall and weighs 38.56 kg (85 lb). Upon assessment, which of the following manifestations should the nurse expect? (Select all that apply.)
- A. Amenorrhea
- B. Verbalized desire to gain weight
- C. Altered body image
- D. Hyperactivity
- E. Bradycardia
Correct Answer: A, C, D, E
Rationale: Anorexia nervosa is often associated with amenorrhea, distorted body image, excessive activity, and bradycardia due to malnutrition.
A nurse is caring for a client who has a mental illness. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?
- A. Encouraging client feedback about satisfaction with the facility experience
- B. Explaining unit rules and policies regarding unacceptable behaviors
- C. Supporting the client’s wish to refuse prescribed medications
- D. Making sure the client understands expectations for participation
Correct Answer: C
Rationale: The correct answer is C: Supporting the client’s wish to refuse prescribed medications. Autonomy refers to the client's right to make their own decisions about their care. By supporting the client's wish to refuse medications, the nurse is respecting the client's autonomy and right to make decisions about their treatment. This empowers the client to have control over their own healthcare decisions.
Explanation for incorrect choices:
A: Encouraging client feedback about satisfaction with the facility experience - This choice relates to client satisfaction but does not directly address autonomy.
B: Explaining unit rules and policies regarding unacceptable behaviors - This choice focuses on rules and policies, not autonomy.
D: Making sure the client understands expectations for participation - This choice is about ensuring understanding, not necessarily autonomy.
A nurse is assessing a client who has a history of alcohol use disorder. Which of the following questions should the nurse include to determine how alcohol use affects the client's psychosocial behaviors?
- A. "Has alcohol use affected your performance at work?"
- B. "Have you received prior treatment for substance use disorder?"
- C. "Do you receive treatment for any mental health disorders?"
- D. "At what age did you begin drinking alcohol?"
Correct Answer: A
Rationale: The correct answer is A. By asking if alcohol use has affected the client's performance at work, the nurse can assess the impact of alcohol on the client's psychosocial behaviors, such as work productivity and relationships with colleagues. This question directly addresses the behavioral consequences of alcohol use.
Explanation for incorrect choices:
B: Asking about prior treatment for substance use disorder focuses on the past rather than the current impact on psychosocial behaviors.
C: Inquiring about treatment for mental health disorders is relevant but does not specifically address the psychosocial effects of alcohol use.
D: Asking at what age the client began drinking alcohol provides historical information but does not assess current psychosocial behaviors.
A nurse is caring for a client who is dying. The client says, "My mother died in the hospital, but I did not get there before she died." Which of the following statements should the nurse make?
- A. "We will call your family in time for them to get here."
- B. "I wonder if you are fearful of dying alone."
- C. "I will make sure a staff member is in your room at all times."
- D. "I will tell your family of your concern so that they can be here."
Correct Answer: B
Rationale: The correct answer is B: "I wonder if you are fearful of dying alone." This response shows empathy and addresses the client's emotional needs. It acknowledges the client's fear and opens up a conversation about their concerns. It allows the client to express their feelings and provides an opportunity for therapeutic communication.
Choice A is incorrect because it only focuses on calling the family and does not address the client's emotional state. Choice C is incorrect as it only ensures physical presence but does not address the client's emotional needs. Choice D is incorrect as it shifts the responsibility to the family without acknowledging the client's feelings.
A nurse in a mental health facility is interacting with a client who is angry and becoming increasingly aggressive. Which of the following actions should the nurse take?
- A. Move the client to a private area so the conversation will not be disturbed.
- B. Use clarification to determine what the client is feeling.
- C. Speak to the client using an authoritative voice.
- D. Maintain constant eye contact with the client.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Moving the client to a private area ensures privacy, reduces stimulation, and promotes a sense of safety, which can help de-escalate the situation. It also prevents the client from feeling embarrassed or judged by others, allowing for more open communication. This approach prioritizes the client's emotional well-being and safety.
Summary:
B: While clarification is important for understanding the client's emotions, it may not be the most immediate action needed in a potentially escalating situation.
C: Speaking authoritatively may further agitate the client and escalate the situation.
D: Maintaining constant eye contact could be perceived as confrontational and may escalate aggression.