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A nurse is reviewing laboratory findings for a client who has been taking lithium for 6 months. Which of the following findings should the nurse report to the provider?
- A. Lithium level 0.8 mEq/L
- B. Sodium 130 mEq/L
- C. Creatinine 1.5 mg/dL
- D. WBC 8,000/mm³
Correct Answer: C
Rationale: The correct answer is C: Creatinine 1.5 mg/dL. This finding should be reported because an elevated creatinine level indicates impaired kidney function, which can lead to lithium toxicity. Lithium is primarily excreted by the kidneys, and impaired renal function can result in lithium accumulation in the body, increasing the risk of adverse effects. Reporting this finding promptly will allow the provider to adjust the dosage of lithium to prevent toxicity.
Choices A, B, and D are within normal ranges and do not directly indicate lithium toxicity. A lithium level of 0.8 mEq/L is within the therapeutic range (0.6-1.2 mEq/L). Sodium level of 130 mEq/L is also within normal limits. WBC count of 8,000/mm³ is normal and not directly related to lithium toxicity. Therefore, these findings do not require immediate reporting compared to the elevated creatinine level.
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A nurse in an alcohol treatment facility is caring for a client who states 'my job is so stressful that the only way I can cope is to drink.' The nurse should recognize that the client is displaying which of the following defense mechanisms?
- A. Repression
- B. Rationalization
- C. Introjection
- D. Intellectualization
Correct Answer: B
Rationale: The correct answer is B: Rationalization. Rationalization is a defense mechanism where individuals justify their behaviors or feelings with logical reasoning or excuses. In this case, the client is justifying their drinking by attributing it to the stress of their job. This defense mechanism helps the individual avoid facing the real underlying issues causing their behavior.
Choice A: Repression involves pushing unwanted thoughts or feelings into the unconscious mind, which is not demonstrated by the client's statement.
Choice C: Introjection is the internalization of external beliefs or values, not applicable in this context.
Choice D: Intellectualization is the process of focusing on facts and logic to avoid dealing with emotions, which is not evident in the client's statement.
A nurse is developing a behavioral contract with a client who has antisocial personality disorder. Which of the following client goals should the nurse include in the contract?
- A. Use projection during group therapy
- B. Increase self-esteem
- C. Use bargaining skills for behavioral consequences
- D. Decrease the number of verbal outbursts
Correct Answer: D
Rationale: The correct answer is D: Decrease the number of verbal outbursts. For a client with antisocial personality disorder, managing impulsivity and aggression is crucial. Decreasing verbal outbursts helps improve social interactions and relationships. Using projection (A) can exacerbate manipulative behavior. Increasing self-esteem (B) may not address the core issues of the disorder. Using bargaining skills (C) might reinforce manipulative tendencies rather than promoting genuine change in behavior.
A nurse is providing discharge teaching to the parents of a child who has ADHD and a prescription for methylphenidate. Which of the following instructions should the nurse include?
- A. Administer the medication at bedtime
- B. Monitor the child’s weight frequently
- C. Give the medication with milk
- D. Discontinue the medication if insomnia occurs
Correct Answer: B
Rationale: The correct answer is B: Monitor the child’s weight frequently. This is important because methylphenidate, a stimulant used to treat ADHD, can potentially lead to appetite suppression and weight loss in children. Regular monitoring of the child's weight can help identify any significant changes and allow for appropriate interventions if needed.
Choice A is incorrect because administering the medication at bedtime can lead to insomnia due to its stimulant effects. Choice C is incorrect as there is no specific recommendation to give the medication with milk. Choice D is incorrect because insomnia is a common side effect of methylphenidate and does not necessarily warrant discontinuation of the medication unless severe or persistent.
A nurse is caring for a client in the emergency department who states she was beaten and sexually assaulted by her partner. After a rapid assessment, which of the following actions should the nurse plan to take next?
- A. Conduct a pregnancy test
- B. Request mental health consultation for the client
- C. Provide a trained advocate to stay with the client
- D. Offer prophylactic medication to prevent STI’s
- E. A client who describes having persistent feelings of anger about the hurricane.
Correct Answer: A
Rationale: The correct answer is A: Conduct a pregnancy test. This action is important to assess the client's risk of pregnancy resulting from the sexual assault. Pregnancy testing is crucial for timely decision-making regarding emergency contraception. This step is a priority in the care of a sexual assault survivor. It ensures appropriate medical intervention and support for the client's physical and emotional well-being.
Summary of other choices:
B: Requesting mental health consultation is important but not the immediate next step.
C: Providing a trained advocate is valuable for support but does not address the urgent medical needs of the client.
D: Offering prophylactic medication for STIs is important but not the immediate next step before assessing pregnancy risk.
E: This choice is unrelated to the situation described and should not be considered in this context.
A nurse is providing teaching to a client who has schizophrenia and is prescribed risperidone. Which of the following instructions should the nurse include?
- A. Avoid direct sunlight
- B. Rise slowly from a sitting position
- C. Take the medication on an empty stomach
- D. Expect weight loss as a side effect
Correct Answer: B
Rationale: The correct answer is B: Rise slowly from a sitting position. This instruction is crucial because risperidone can cause orthostatic hypotension, leading to dizziness or fainting when standing up quickly. By rising slowly, the client can minimize the risk of falls. Avoiding direct sunlight (A) is not directly related to risperidone use. Taking the medication on an empty stomach (C) is not necessary for risperidone. Expecting weight loss (D) is not a common side effect of risperidone; in fact, weight gain is more common.