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A young adult client with a recent diagnosis of bipolar disorder takes lithium carbonate daily. The client informed the school nurse of the desire to live away from home to attend college after graduating in one month. Which information is most important for the nurse to provide the client and his family?
- A. The client should be aware of the signs and symptoms of his illness.
- B. The client should plan to participate in group or individual therapy while at college.
- C. Despite the illness, the client should be able to live away from home.
- D. The client's serum lithium levels should be routinely evaluated.
Correct Answer: D
Rationale: Routine monitoring of serum lithium levels is crucial to ensure therapeutic levels and prevent lithium toxicity, especially critical for a newly diagnosed client transitioning to college.
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A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?
- A. Concentrate on and ventilate emotions when distressed.
- B. Shift attention from self to the needs and requests of others.
- C. Relax and reduce the amount of effort to solve the problem.
- D. Focus on small achievable tasks, not taxing problems.
Correct Answer: D
Rationale: Focusing on small achievable tasks can reduce feelings of overwhelm and improve self-efficacy in a client with depression. Ventilating emotions may exacerbate distress, shifting attention may neglect personal needs, and relaxation may perpetuate helplessness.
A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?
- A. Compromised family coping.
- B. Ineffective sexual patterns.
- C. Impaired environmental interpretation.
- D. Disturbed sensory perception.
Correct Answer: D
Rationale: Delusional beliefs indicate disturbed sensory perception, the priority problem requiring psychiatric evaluation.
The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?
- A. Sweet potatoes.
- B. Spinach salad.
- C. Bananas.
- D. Fish.
Correct Answer: B
Rationale: Spinach is high in oxalates, contributing to calcium oxalate stone formation. Sweet potatoes, bananas, and fish are generally safe.
When the nurse addresses questions to an adult female client who is depressed, the client's responses are delayed. Which intervention should the nurse include in this client's plan of care?
- A. Spend time sitting in silence with the client.
- B. Involve the client in a daily exercise program.
- C. Ask the client to describe her depression.
- D. Observe for signs of possible psychosis.
Correct Answer: A
Rationale: Spending time in silence creates a supportive environment, allowing the client to communicate at her pace, addressing delayed responses.
History and Physical
Laboratory Results
Imaging Studies
Initial vital signs
Vital signs
The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and was recently diagnosed with end-stage renal disease (ERSD). She has been placed on hemodialysis three times a week for one month. She presents to the emergency department (ED) with fatigue, generalized weakness, muscle cramps, tingling sensation in her arms and legs, and lightheadedness following 3 days of Illness during which her husband reports she has complained of nausea and had a poor appetite and not able to go for her scheduled dialysis.
On further assessment, the client reports that her doctor had recently started her on Lisinopril for blood pressure control but it "doesn't seem to help". She then complained of some chest discomfort. The client is moved to an ED room and another set of vital signs is performed. Physician notified and orders received.
Select the client actions that were effective in her treatment.
- A. Denies cramps, weakness, or nausea
- B. BP 116/68 mm Hg, HR 75 bpm
- C. Potassium level 3.6 mEq/L (3.6 mmol/L)
- D. Verbalizes commitment to dialysis appointments
- E. Client states that she will need to resume her Lisinopril to control blood pressure
- F. The client is eager to add dark green vegetables and potatoes to her diet
Correct Answer: B,C,D
Rationale: Stable BP/HR, normal potassium, and dialysis commitment indicate effective treatment. Denying symptoms needs investigation, resuming Lisinopril requires provider guidance, and high-potassium foods are inappropriate.