Nokea
An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. After starting medication therapy, the nurse notices the client has more energy, is giving away her belongings, and has an elevated mood. Which intervention is best for the nurse to implement?
- A. Support the client by telling her what wonderful progress she is making.
- B. Ask the client if she has had any recent thoughts of harming herself.
- C. Reassure the client that the antidepressant drugs are apparently effective.
- D. Tell the client to keep her belongings because she will need them at discharge.
Correct Answer: B
Rationale: When a client with major depressive disorder shows signs of increased energy, giving away belongings, and an elevated mood, it could indicate a shift towards suicidal behavior. Therefore, the best intervention for the nurse is to ask the client if she has had any recent thoughts of harming herself. This is crucial to assess the client's risk for suicide and provide necessary interventions. Choices A, C, and D are incorrect because they do not address the potential risk of harm to the client and do not prioritize the immediate assessment required in this situation.
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A client with acute pancreatitis is receiving total parenteral nutrition (TPN). Which laboratory value should the nurse monitor closely?
- A. Serum potassium
- B. Serum glucose
- C. Serum triglycerides
- D. Serum calcium
Correct Answer: C
Rationale: In a client with acute pancreatitis receiving total parenteral nutrition (TPN), the nurse should monitor serum triglycerides closely. Acute pancreatitis can lead to fat malabsorption, making the client susceptible to hypertriglyceridemia. Monitoring serum triglycerides is crucial to prevent complications such as hyperlipidemia. While monitoring serum potassium, glucose, and calcium levels is also essential in various conditions, in this scenario, the primary concern is the risk of developing hypertriglyceridemia due to fat malabsorption.
A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which laboratory value is most concerning?
- A. INR of 3.0
- B. Prothrombin time (PT) of 15 seconds
- C. Hemoglobin of 10 g/dl
- D. White blood cell count
Correct Answer: A
Rationale: An INR of 3.0 is most concerning in a client prescribed warfarin (Coumadin) as it indicates a high risk of bleeding, requiring immediate intervention. A high INR value suggests that the blood is taking longer to clot, putting the patient at an increased risk of hemorrhage. Prothrombin time (PT) measures how long it takes for blood to clot, but the specific value of 15 seconds is within the normal range. Hemoglobin of 10 g/dl indicates mild anemia and does not directly relate to the risk of bleeding associated with warfarin therapy. White blood cell count assesses immune function and infection risk, but it is not directly related to the anticoagulant effects of warfarin.
Following a lumbar puncture, a client voices several complaints. What complaint indicates to the nurse that the client is experiencing a complication?
- A. I am having pain in my lower back when I move my legs
- B. My throat hurts when I swallow
- C. I feel sick to my stomach and am going to throw up
- D. I have a headache that gets worse when I sit up
Correct Answer: D
Rationale: The correct answer is D. A post-lumbar puncture headache, ranging from mild to severe, may occur as a result of leakage of cerebrospinal fluid at the puncture site. This complication is usually managed by bed rest, analgesics, and hydration. Choices A, B, and C do not directly indicate complications associated with a lumbar puncture. Pain in the lower back when moving legs, a sore throat when swallowing, and nausea with a feeling of vomiting are not typical complications of lumbar puncture.
A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which laboratory value is most concerning?
- A. Serum glucose of 300 mg/dl
- B. Serum bicarbonate of 18 mEq/L
- C. Serum potassium of 5.5 mEq/L
- D. Serum sodium of 135 mEq/L
Correct Answer: C
Rationale: A serum potassium level of 5.5 mEq/L is concerning in a client with DKA as it may indicate worsening hyperkalemia, requiring immediate intervention. Elevated serum potassium levels can lead to life-threatening cardiac arrhythmias. While elevated glucose and low bicarbonate are characteristic of DKA, hyperkalemia poses a higher immediate risk. Serum sodium within the normal range is not typically a primary concern in DKA.
The nurse is assessing a client with chronic heart failure who is receiving furosemide (Lasix). Which assessment finding is most concerning?
- A. Heart rate of 60 beats per minute
- B. Blood pressure of 110/70 mmHg
- C. Elevated liver enzymes
- D. Elevated blood glucose level
Correct Answer: C
Rationale: Elevated liver enzymes are most concerning in a client with chronic heart failure as they may indicate liver congestion or worsening heart failure, requiring immediate intervention. Elevated liver enzymes can be a sign of hepatotoxicity or liver damage, which could be a result of furosemide (Lasix) use. Monitoring liver function is crucial in patients taking furosemide due to the risk of hepatotoxicity. A heart rate of 60 beats per minute and a blood pressure of 110/70 mmHg are within normal ranges for a client with chronic heart failure. An elevated blood glucose level may be expected due to the effects of furosemide but is not as immediately concerning as elevated liver enzymes.