Nokea
A nurse is contributing to the plan of care for a client who has a new prescription for lithium. Which of the following interventions should the nurse recommend?
- A. Increase the client's daily caloric intake.
- B. Administer the medication with meals.
- C. Monitor the client for hypoglycemia.
- D. Decrease the client's dietary potassium.
Correct Answer: B
Rationale: Administering lithium with meals is recommended to reduce gastrointestinal upset. Lithium can cause stomach irritation, and taking it with food helps minimize this side effect, improving adherence.
You may also like to solve these questions
A nurse is collecting data for a health history from a client who has antisocial personality disorder. Which of the following clinical findings is associated with this disorder?
- A. Withdrawn behaviors.
- B. Blunted affect.
- C. Excessively anxious.
- D. Exploitive of others.
Correct Answer: D
Rationale: Exploitive of others is a key characteristic of antisocial personality disorder. Individuals often disregard others’ rights and manipulate them for personal gain, aligning with the disorder’s profile.
A nurse is caring for a client who becomes extremely agitated and asks if they can go to a separate room to be alone for an hour. The nurse should document which of the following de-escalation techniques in the client's medical record?
- A. Therapeutic hold.
- B. Restraint.
- C. Diversion.
- D. Timeout.
Correct Answer: D
Rationale: Timeout allows the client to have a moment away from stimuli to regain control and calm down, which is a recognized de-escalation technique. This matches the client’s request and supports de-escalation efforts.
A nurse is caring for an adolescent who was recently sexually assaulted. Which of the following statements by the adolescent's guardian represents the presence of a positive support system?
- A. I can encourage my child to think about what they did that allowed this event to happen.
- B. I anticipate that my child will feel some self-blame.
- C. I should encourage my child to focus solely on the future.
- D. I will have to do all I can to monitor my child's relationships.
Correct Answer: D
Rationale: Actively monitoring the adolescent's relationships can demonstrate vigilance and support, helping to create a safe environment for recovery. This shows a proactive, protective stance, indicative of a positive support system.
A nurse is caring for a newly admitted client who has obsessive-compulsive disorder. Which of the following actions should the nurse take first?
- A. Discuss the benefits of relaxation exercises with the client.
- B. Explain the use of response prevention to the client.
- C. Administer an antianxiety medication.
- D. Calculate the client's score on the Hamilton Rating Scale for Anxiety.
Correct Answer: D
Rationale: Calculating the Hamilton Rating Scale for Anxiety provides an initial assessment of the client's anxiety severity, guiding further interventions. This baseline data collection is the priority upon admission to tailor subsequent care.
Nurses' Notes
0800: Client is 3 days postoperative. Currently disoriented to time and place, oriented to self. Client is displaying disorganized thinking, a lack of attention when spoken to, and rambling speech that is incoherent at times. Client attempts to get out of bed without assistance. Changes in client's behavior began the prior evening and client has been awake most of the night. Client has refused to eat or drink since the previous day. Intake and output from previous day: 250 mL intake, 2,500 mL output. Call placed to provider to report findings.
0830: IV fluids initiated by RN. Urine and blood samples collected per provider's prescription. Client continues to be restless.
Vital Signs
• Heart rate: 115/min
• Respiratory rate: 20/min
• Blood pressure: 90/65 mm Hg
• Temperature: 38.6°C (101.5°F)
A nurse is caring for an older adult client who is postoperative.Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 arameters the nurse should monitor to collect data about the client's progress.
- A. Delirium,Depression,Alzheimer's disease,Generalized anxiety disorder
- B. Encourage family members to stay with the client,Assist the client to identify coping skills,Monitor the client's fluid intake and output,Encourage the client to exercise.
- C. Suicidal ideation,Weight loss,Fall risk,Sleep-wake cycle
Correct Answer: A
Rationale: Delirium fits acute postoperative confusion. Family presence reassures, fluid monitoring addresses dehydration, and tracking fall risk and sleep assess safety and recovery.