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A nurse is caring for a client who has a lithium level of 0.8 mEq/L. Which of the following actions should the nurse take?
- A. Withhold the next dose of lithium
- B. Repeat the lithium level test
- C. Administer the next dose of lithium
- D. Recommend a low sodium diet
Correct Answer: C
Rationale: The correct answer is C: Administer the next dose of lithium. A lithium level of 0.8 mEq/L is within the therapeutic range (0.6-1.2 mEq/L), so the nurse should continue the medication as prescribed. Withholding the dose (choice A) can lead to subtherapeutic levels and ineffective treatment. Repeating the test (choice B) is unnecessary as the current level is within the therapeutic range. Recommending a low sodium diet (choice D) is not directly related to lithium therapy.
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A nurse is assessing a client who is withdrawing from heroin. Which of the following manifestations should the nurse expect?
- A. Slurred speech
- B. Hypotension
- C. Bradycardia
- D. Hyperthermia
Correct Answer: D
Rationale: The correct answer is D: Hyperthermia. Heroin withdrawal can lead to hyperthermia due to increased metabolic activity, dehydration, and dysregulation of the body's temperature control mechanisms. Slurred speech (A) is not a typical manifestation of heroin withdrawal. Hypotension (B) and bradycardia (C) are more commonly associated with opioid overdose rather than withdrawal. In withdrawal, the client may actually experience hypertension and tachycardia due to increased sympathetic activity.
A nurse in an inpatient mental health facility is planning care for a client who has schizophrenia and is experiencing delusions. Which of the following interventions should the nurse include?
- A. Encourage the client to focus on reality-based topics
- B. Agree with the client’s delusional beliefs
- C. Discuss the delusions in detail
- D. Provide frequent reassurance about safety
Correct Answer: A
Rationale: The correct answer is A: Encourage the client to focus on reality-based topics. This intervention is appropriate because it helps the client ground themselves in reality and potentially reduce the intensity of their delusions. By redirecting the client's focus to reality-based topics, the nurse can help them challenge and eventually overcome their delusions. Choices B, C, and D are incorrect. Agreeing with delusional beliefs can reinforce them, discussing delusions in detail may exacerbate them, and providing frequent reassurance about safety may not address the underlying issue of delusions.
A nurse is teaching about benztropine to a client who has schizophrenia. Which of the following statements should the nurse include in the teaching?
- A. This medication is given to help with extrapyramidal side effects
- B. This medication is given to help with your depression
- C. Benztropine helps alleviate your hallucinations
- D. Benztropine is used to counteract your tachycardia
Correct Answer: A
Rationale: Correct Answer: A: This medication is given to help with extrapyramidal side effects.
Rationale:
1. Benztropine is an anticholinergic medication commonly used to manage extrapyramidal side effects (EPS) caused by antipsychotic medications.
2. EPS include symptoms like tremors, muscle stiffness, and restlessness, which can occur with antipsychotic use.
3. By blocking certain neurotransmitters in the brain, benztropine helps alleviate these side effects.
4. Other choices are incorrect:
- B: Benztropine does not treat depression, as it is not an antidepressant.
- C: Benztropine does not directly address hallucinations, which are typically managed with antipsychotic medications.
- D: Benztropine does not specifically target tachycardia, which may be a side effect of other medications but not the primary indication for benztropine use.
A nurse is caring for a school-aged child who has conduct disorder and is being physically aggressive toward other children in the unit. Which of the following actions should the nurse take first?
- A. Place the child in seclusion
- B. Use therapeutic hold technique
- C. Apply wrist restraints
- D. Administer risperidone
Correct Answer: A
Rationale: The correct answer is A: Place the child in seclusion. The first step in managing physically aggressive behavior in a child with conduct disorder is to ensure the safety of the child and others. Placing the child in seclusion helps prevent harm to others while allowing the child to calm down in a controlled environment. Using therapeutic hold technique (B) or applying wrist restraints (C) may escalate the situation and increase the risk of harm. Administering risperidone (D) is a medication intervention that should be considered only after addressing the immediate safety concerns.
A nurse is caring for a client who has schizophrenia and takes clozapine. Which of the following findings is a priority for the nurse to report to the provider?
- A. Nausea
- B. Random blood glucose 130 mg/dL
- C. Heart rate 104 per minute
- D. Sore throat
Correct Answer: D
Rationale: The correct answer is D: Sore throat. A priority finding to report with clozapine is agranulocytosis, which presents with symptoms like sore throat. This is crucial to detect early to prevent severe infection. A: Nausea is a common side effect of clozapine but not a priority over potential agranulocytosis. B: Random blood glucose of 130 mg/dL is slightly elevated but not an immediate concern. C: Heart rate of 104 per minute may be a side effect but is not as critical as agranulocytosis. Reporting the sore throat promptly can lead to timely intervention and prevent serious complications.