Nokea
A patient prescribed lithium telephones the nurse at the clinic to say, 'I've had severe diarrhea 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?' What instructions should the nurse provide?
- A. Restrict oral fluids for 24 hours and stay in bed.'
- B. Have someone bring you to the clinic immediately.'
- C. Drink a large glass of water with 1 teaspoon of salt added.'
- D. Take an over-the-counter antidiarrheal medication hourly until the diarrhea subsides.'
Correct Answer: B
Rationale: Symptoms suggest lithium toxicity, requiring immediate evaluation. Other options may worsen the condition or delay treatment.
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A patient diagnosed with bipolar disorder is dressed in a red leotard and brightly colored scarves. The patient cusses while twirling and shadowboxing. Then the patient says gaily, 'Do you like my scarves? Here... they are my gift to you.' How should the nurse document the patient's mood?
- A. Labile and euphoric
- B. Irritable and belligerent
- C. Highly suspicious and arrogant
- D. Excessively happy and confident
Correct Answer: A
Rationale: The patient has demonstrated angry behavior and pleasant, happy behavior within seconds of each other. Excessive happiness indicates euphoria. Mood swings are often rapid and seemingly without understandable reason in patients who are manic. These swings are documented as labile.
A patient experiencing mania has not eaten or slept for 3 days. Which nursing diagnosis has priority?
- A. Risk for injury
- B. Ineffective coping
- C. Impaired social interaction
- D. Ineffective therapeutic regimen management
Correct Answer: A
Rationale: Hyperactivity and poor judgment place the patient at risk for injury, making this the priority nursing diagnosis to ensure physiological safety.
At a unit meeting, staff members discuss the decor for a special room for patients experiencing mania. What select is the best option?
- A. Extra-large window with a view of the street
- B. Neutral walls with pale, simple accessories
- C. Brightly colored walls and print drapes
- D. Deep colors for walls and upholstery
Correct Answer: B
Rationale: A nonstimulating environment with neutral decor reduces sensory overload for manic patients. Other options may overstimulate or pose safety risks.
A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, 'Do I have to keep taking this lithium even though my mood is stable now?' Select the nurse's most appropriate response.
- A. You will be able to stop the medication in approximately 1 month.'
- B. Taking the medication every day helps prevent relapses and recurrences.'
- C. Usually patients take this medication for approximately 6 months after discharge.'
- D. It's unusual that the health care provider has not already stopped your medication.'
Correct Answer: B
Rationale: Lithium maintenance prevents recurrences, and this response promotes compliance. Other options provide incorrect information.
A patient diagnosed with bipolar disorder is hyperactive and manic after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate?
- A. Stop that! No one did anything to provoke an attack by you.'
- B. If you do that one more time, you will be secluded immediately.'
- C. Do not hit anyone. If you are unable to control yourself, we will help you.'
- D. You know we will not let you hit anyone. Why do you continue this behavior?'
Correct Answer: C
Rationale: Setting limits in simple, concrete terms helps de-escalate the situation while offering assistance. The other options either threaten punishment or fail to provide environmental safety.