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During a unit card game, a client with acute mania begins to sing loudly as she starts to undress. The nurse should:
- A. Ignore the client's behavior.
- B. Exchange the cards for a checker board.
- C. Send the other clients to their rooms.
- D. Cover the client and walk her to her room.
Correct Answer: D
Rationale: Covering the client and escorting her to a private area maintains dignity and safety, de-escalating the situation caused by manic behavior.
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On morning rounds, the nurse found a manic-depressive client who is taking lithium in a confused mental state, vomiting, twitching, and exhibiting a coarse hand tremor. Which one of the following nursing actions is essential at this time?
- A. Administer her next dosage of lithium, and then call the physician.
- B. Withhold her lithium, and report her symptoms to the physician.
- C. Place her on NPO to decrease the excretion of lithium from her body, and call the physician.
- D. Contact the lab and request a lithium level in 30 minutes, and call the physician.
Correct Answer: B
Rationale: The client has lithium toxicity, and the nurse must withhold further dosages. Because of her level of toxicity, further lithium could cause coma and death. The nurse needs further orders from the physician to stabilize the client's lithium level.
The nurse is teaching a client with a history of hyperlipidemia about dietary modifications. The nurse should tell the client to avoid:
- A. Saturated fats
- B. Lean proteins
- C. Complex carbohydrates
- D. Fresh fruits
Correct Answer: A
Rationale: Saturated fats increase LDL cholesterol, worsening hyperlipidemia, so they should be avoided to reduce cardiovascular risk.
The parents of a child with cystic fibrosis ask what determines the prognosis of the disease. The nurse knows that the greatest determinant of the prognosis is:
- A. The degree of pulmonary involvement
- B. The ability to maintain an ideal weight
Correct Answer: A
Rationale: Pulmonary involvement is the primary determinant of prognosis in cystic fibrosis, as progressive lung disease is the leading cause of morbidity and mortality.
The nurse would assess the client's correct understanding of the fertility awareness methods that enhance conception, if the client stated that:
- A. My sexual partner and I should have intercourse when my cervical mucosa is thick and cloudy.'
- B. At ovulation, my basal body temperature should rise about 0.5F.'
- C. I should douche immediately after intercourse.'
- D. My sexual partner and I should have sexual intercourse on day 14 of my cycle regardless of the length of the cycle.'
Correct Answer: B
Rationale: A slight rise in basal body temperature (about 0.5°F) after ovulation, due to progesterone, indicates correct understanding of fertility awareness.
The nurse is caring for a client with acquired immunodeficiency syndrome. Which finding should be reported to the doctor immediately?
- A. Temperature of 100.2°F
- B. White patches on the tongue
- C. Weight loss of 10 pounds
- D. Respiratory rate of 26 breaths per minute
Correct Answer: D
Rationale: A respiratory rate of 26 breaths per minute suggests respiratory distress, a critical issue in AIDS due to possible opportunistic infections like Pneumocystis pneumonia, requiring immediate reporting.