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A nurse is developing a plan of care for a client with bipolar I disorder,hospitalized for heart failure and showing signs of lithium toxicity. Which of the following interventions should the nurse include? (Select all that apply.)
- A. Set up a dietary consult for a low-sodium diet.
- B. Notify the provider of potential medication interactions.
- C. Withhold next dose of lithium.
- D. Educate the client about the need for hemodialysis.
- E. Discuss contraception.
- F. Assess need for and administer prochlorperazine PRN.
Correct Answer: B
Rationale:
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A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia. The client's parents are tearful and express feelings of guilt. Which of the following is an appropriate statement by the nurse?
- A. Your provider has explained the causes of schizophrenia. Why do you feel guilty about your daughter's diagnosis?
- B. You said that you feel guilty about your daughter's diagnosis. Let's talk about what is causing you to feel this way.
- C. You should not feel guilty about your daughter's diagnosis. Schizophrenia is unpreventable.
- D. I'm sure your daughter's diagnosis is very difficult to deal with, but everything will be all right once she receives the proper treatment.
Correct Answer: B
Rationale: Rationale: Choice B is the correct answer because it acknowledges the parents' feelings of guilt and opens the door for communication. By reflecting the parents' emotions and offering to discuss the underlying reasons, the nurse is validating their feelings and promoting therapeutic communication. This approach fosters trust and allows the parents to express their concerns, ultimately leading to better understanding and support.
Incorrect Choices:
A: This response may come off as confrontational by questioning the parents' feelings of guilt, potentially making them defensive and hindering open communication.
C: While it is true that schizophrenia is not preventable, simply stating this does not address the parents' emotional needs or provide support.
D: This response minimizes the parents' feelings and offers false reassurance without addressing the root cause of their guilt.
A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as possible risk factors for iron deficiency anemia?
- A. The client eats red meat daily.
- B. The client has had gastric bypass surgery.
- C. The client has had treatment for gastrointestinal cancer.
- D. The client eats mostly prepackaged,processed foods.
- E. The client has ulcerative colitis.
Correct Answer: B,C,D,E
Rationale: The correct answer includes choices B, C, D, and E. Gastric bypass surgery can lead to malabsorption of iron, increasing the risk of anemia. Treatment for gastrointestinal cancer can also affect iron absorption. Eating mostly prepackaged, processed foods may lack iron-rich foods, contributing to anemia risk. Ulcerative colitis can cause intestinal bleeding, leading to iron deficiency. Choice A is incorrect as red meat is a good source of iron.
A nurse is educating a 28-year-old female client about the impacts of hypothyroidism on overall health. Which of the following statements would the nurse include in the teaching?
- A. If you become pregnant, low thyroid hormone levels can affect your developing fetus.
- B. Hypothyroidism can cause autoimmune disorders over time.
- C. Low thyroid hormone levels will cause your metabolism to speed up and heart rate to increase.
- D. Low blood pressure is usually associated with hypothyroidism.
Correct Answer: A
Rationale: Rationale: The correct answer is A because hypothyroidism, characterized by low thyroid hormone levels, can lead to complications during pregnancy, affecting fetal development. This is due to the essential role of thyroid hormones in fetal brain and nervous system development.
Summary of Incorrect Choices:
B: Hypothyroidism is linked to autoimmune disorders, not a consequence of it.
C: Hypothyroidism actually slows down metabolism and heart rate due to decreased thyroid hormone levels.
D: Low blood pressure is more commonly associated with hyperthyroidism, where the thyroid is overactive.
A nurse is reviewing the history and physical of an adolescent client diagnosed with conduct disorder. The nurse recognizes that which of the following is an expected assessment finding of conduct disorder?
- A. Death of client's father two months ago
- B. Experiences frequent facial tics
- C. Adheres strictly to routines
- D. Suspended from school several times in the past year
Correct Answer: D
Rationale: The correct answer is D: Suspended from school several times in the past year. Conduct disorder is characterized by persistent patterns of behavior that violate the rights of others and societal norms. Being suspended from school multiple times indicates a disregard for rules and authority, which is a common feature of conduct disorder. Choices A, B, and C do not directly align with the typical behaviors associated with conduct disorder. A recent death in the family (A) may lead to emotional distress but is not a defining characteristic of conduct disorder. Frequent facial tics (B) are more indicative of a neurological or psychological condition, not conduct disorder. Adhering strictly to routines (C) is more characteristic of obsessive-compulsive disorder, not conduct disorder.
A nurse is providing teaching to a client diagnosed with schizophrenia and is prescribed haloperidol (Haldol). Which of the following information should the nurse include in the teaching?
- A. This medication will decrease your symptoms of OCD.
- B. This medication may cause excessive salivation.
- C. You can stop taking the medication if the side effects are bothersome.
- D. You may experience dizziness upon standing while taking this medication.
Correct Answer: D
Rationale: The correct answer is D: You may experience dizziness upon standing while taking this medication. This is important information to include because haloperidol can cause orthostatic hypotension, leading to dizziness upon standing. This is a common side effect that the client should be aware of to prevent falls. Option A is incorrect because haloperidol is not used to treat OCD. Option B is incorrect because excessive salivation is not a common side effect of haloperidol. Option C is incorrect because it is crucial not to stop taking antipsychotic medications abruptly without consulting a healthcare provider.