Nokea
A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?
- A. Experiencing diarrhea
- B. Exercising moderately
- C. Increasing sodium intake
- D. Drinking green tea
Correct Answer: A
Rationale: The correct answer is A: Experiencing diarrhea. Diarrhea can lead to dehydration and electrolyte imbalances, which can increase lithium levels in the blood and cause toxicity. This is because lithium is primarily excreted by the kidneys, and dehydration can impair its elimination. Options B, C, and D are incorrect because moderate exercise, increasing sodium intake, and drinking green tea are not known to directly cause lithium toxicity. In fact, maintaining adequate hydration and a balanced diet with normal sodium intake can help prevent lithium toxicity.
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A school nurse is talking with a 13-year-old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address?
- A. "My parents treat me like a baby sometimes."
- B. "I haven't gotten my period yet, and all my friends have theirs."
- C. "None of the kids at this school like me, and I don't like them either."
- D. "There's a big pimple on my face, and I worry that everyone will notice it."
Correct Answer: C
Rationale: The correct answer is C. The nurse's priority should be to address the adolescent's statement about not liking any kids at school and feeling disliked by others. This suggests potential social isolation, which can impact mental health and well-being. Addressing social relationships is crucial at this age for emotional development. Choices A, B, and D are important but not urgent concerns. Choice A relates to family dynamics, B to physical development, and D to self-image; while these are valid issues, they do not have immediate implications for the adolescent's well-being like the social isolation expressed in choice C.
A nurse is caring for a client who professes a deep and everlasting love for his girlfriend one day and the next day refuses to speak to her or allow her to visit. The nurse recognizes this client behavior as which of the following defense mechanisms?
- A. Repression
- B. Splitting
- C. Sublimation
- D. Undoing
Correct Answer: B
Rationale: Splitting is characterized by viewing things as all good or all bad, commonly seen in personality disorders.
A nurse is caring for an adolescent who is experiencing indications of depression. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Irritability
- B. Euphoria
- C. Chronic pain
- D. Social withdrawal
- E. Changes in appetite
Correct Answer: A, C, D, E
Rationale: Depression in adolescents often presents with irritability, physical complaints (chronic pain), social withdrawal, and appetite changes.
A nurse is caring for a client who is receiving treatment for alcohol withdrawal. Which of the following findings is the highest priority?
- A. Vitamin deficiency
- B. Diaphoresis
- C. Tremors
- D. Visual hallucinations
Correct Answer: D
Rationale: The correct answer is D: Visual hallucinations. Visual hallucinations in a client undergoing alcohol withdrawal indicate severe withdrawal symptoms and potential progression to delirium tremens, a life-threatening condition. Addressing visual hallucinations promptly is crucial to prevent harm or injury to the client. Vitamin deficiency (choice A), diaphoresis (choice B), and tremors (choice C) are common symptoms of alcohol withdrawal but are not as immediately life-threatening as visual hallucinations. Therefore, addressing visual hallucinations takes priority over these symptoms.
A nurse is assessing an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect?
- A. Tachycardia
- B. Constipation
- C. Menorrhagia
- D. Hyperkalemia
Correct Answer: B
Rationale: The correct answer is B: Constipation. In anorexia nervosa, a lack of adequate nutrition intake can lead to decreased gastrointestinal motility, resulting in constipation. Tachycardia (A) is common due to the body's response to malnutrition. Menorrhagia (C) is unlikely as anorexia nervosa often leads to amenorrhea. Hyperkalemia (D) is less likely as potassium levels tend to be low due to decreased food intake.