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A nurse is reinforcing teaching with a client who has bipolar disorder and has a new prescription for lithium. To address possible adverse effects
- A. the nurse should include that which of the following laboratory values will be monitored while the client is taking this medication?
- B. Liver enzymes.
- C. Sodium level.
- D. Uric acid.
- E. Erythrocyte sedimentation rate.
Correct Answer: B
Rationale: Sodium levels must be monitored while taking lithium because lithium can alter sodium and fluid balance. Changes in sodium levels can affect lithium levels and potentially lead to toxicity, making this a critical monitoring parameter.
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A nurse is caring for a client who has depressive disorder following the recent death of their partner. Which of the following responses should the nurse make?
- A. Everyone feels depressed during the grieving process.
- B. I remember how depressed I was after my friend died.
- C. You should start participating in your usual activities.
- D. Tell me what your relationship with your partner was like.
Correct Answer: D
Rationale: Asking about the client’s relationship encourages them to express their feelings and helps the nurse understand their experience to provide support. This fosters a therapeutic dialogue.
Nurses' Notes
0205: Client brought to the ED by police after being found wandering on the street. Client able to provide identity to police but not able to identify place or time. Family notified. Client confused and agitated. Appearance is disheveled. Mucous membranes dry. Lungs clear and equal, heart rhythm regular. During data collection, client states, "Can you ask that person to leave my room?" Client is pointing to an empty chair.
0415: Client's adult child arrived to the ED and went to client's room. Client identified family member. Client is pacing and agitated, and states, "I don't understand why I am here." Adult child asks nurse to talk outside of room and states, "I don't know why they are so confused. They are not normally like this." Adult child states client has past medical history of hypertension and alcohol-related cirrhosis. Upon returning to room, client voided 250 mL of dark yellow, cloudy urine.
Vital Signs
0200:
• Temperature: 38.6°C (101.5°F)
• Heart rate: 104/min
• Respiratory rate: 18/min
• Blood pressure: 158/96 mm Hg
• Oxygen saturation: 98% on room air
0415:
• Temperature: 38.6°C (101.5°F)
• Heart rate: 108/min
• Respiratory rate: 20/min
• Blood pressure: 148/94 mm Hg
• Oxygen saturation: 98% on room air
Provider's Note
0230: Client diagnosis: delirium secondary to a urinary tract infection and dehydration. Will transfer client to medical-surgical unit.
Laboratory Results
0230:
• Serum toxicology screen: Alcohol: 60 mg/dL (80 to 200 mg/dL mild to moderate intoxication)
A nurse is caring for a 65-year-old male client in the emergency department (ED).For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.
- A. Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion.
- B. Administer lorazepam.
- C. Initiate 1:1 supervision.
- D. Administer acyclovir.
Correct Answer: A,B,C
Rationale: IV fluids address dehydration, lorazepam manages agitation or withdrawal, and 1:1 supervision ensures safety due to delirium. Acyclovir is unexpected as no viral infection is indicated.
A nurse is reviewing the medical record of a client who is to receive electroconvulsive therapy. The nurse should notify the provider for which of the following findings?
- A. Asthma.
- B. Crohn's disease.
- C. Renal colic.
- D. Cardiac arrhythmia.
Correct Answer: D
Rationale: Cardiac arrhythmia is a contraindication for ECT because the procedure can increase the risk of cardiac complications. ECT involves electrical stimulation that can affect heart rhythm, requiring prior cardiac evaluation.
A nurse is caring for a client who has an opioid use disorder. The nurse should anticipate that the provider will prescribe which of the following medications for treatment?
- A. Phenobarbital.
- B. Diazepam.
- C. Chlordiazepoxide.
- D. Buprenorphine.
Correct Answer: D
Rationale: Buprenorphine is a partial opioid agonist used in medication-assisted treatment for opioid use disorder, helping to reduce cravings and withdrawal symptoms. It’s specifically indicated for this condition.
A nurse is caring for a client who is experiencing a situational crisis. Which of the following actions should the nurse take first?
- A. Assist with a client referral for social services.
- B. Identify if the client has thoughts of self-harm.
- C. Reinforce teaching on the client's use of coping skills.
- D. Encourage the client to use personal support systems.
Correct Answer: B
Rationale: Identifying thoughts of self-harm is crucial for immediate safety and risk management, making it the priority action. This ensures the client’s well-being is secured before addressing other needs.