Nokea
The client taking lithium for bipolar disorder participated in a recreational game of basketball in the mental health unit gym. The client is now feeling nauseated and shaky, has blurred vision, and is finding it hard to stand. Considering this information, which action should be taken by the nurse?
- A. Instruct the client to sit and rest for a while in a cool place.
- B. Call the HCP to request an order for a STAT serum lithium level.
- C. Give the prn prescribed antiemetic with a large glass of cold water.
- D. Alert the emergency team for the client's impending cardiac arrest.
Correct Answer: B
Rationale: The client is showing signs of lithium (Lithane) toxicity, especially apparent after high levels of physical activity. The HCP should be notified for a STAT lithium level and corrective action.
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The nurse is receiving a report from an ER nurse about a client. Which of the following statements requires additional follow-up?
- A. The client said they have been taking aspirin, but I'm not sure for how long or how much.
- B. The client frequently takes antacids, but they have not taken any in the last three days.
- C. The client stopped taking ibuprofen after developing gastric ulcers.
- D. The client takes Antabuse and has stopped using mouthwash.
Correct Answer: A
Rationale: Aspirin can have an impact on the patient's bleeding risk, so the amount and frequency is important to know. Antacids can change the gastric pH and impact medication absorption, so the nurse should note when they are last taken. Ibuprofen can cause or exacerbate gastric ulcers. Clients who take Antabuse should avoid alcohol in all forms, including avoiding over-the-counter cough medication and mouthwash.
The 17-year-old female is about to have a drug screen test for employment. The adolescent tells the nurse of a recent UTI that was treated with antibiotics. Which antibiotic, if identified by the client, could produce a false-positive urine screening test for opioids?
- A. Cephalexin
- B. Ceftazidime
- C. Amoxicillin
- D. Ciprofloxacin
Correct Answer: D
Rationale: A: Cephalexin (Keflex) does not interfere with urine testing for opioids. B: Ceftazidime (Fortaz), a cephalosporin, does not interfere with urine testing for opioids. C: Amoxicillin (Amoxil), an aminopenicillin, does not interfere with urine testing for opioids. D: Fluoroquinolones, such as ciprofloxacin (Cipro), can cause false-positive urine opiate screens.
The child with CF is receiving albuterol. Which response should the nurse expect if albuterol is achieving the desired therapeutic effect?
- A. Increased heart rate
- B. Improved weight gain
- C. Fewer hospitalizations
- D. Fewer adventitious lung sounds
Correct Answer: D
Rationale: A: Albuterol may increase HR, but this is not the desired therapeutic effect. B: Weight should not be affected by albuterol. C: The use of a bronchodilator has not been demonstrated to decrease hospitalization frequency. D: The desired therapeutic effect of a bronchodilator such as albuterol (Proventil) is a reduction in adventitious (abnormal) breath sounds.
The HCP prescribes risperidone to manage the hallucinations of the client diagnosed with paranoid schizophrenia. Which client statements reflect a need for further education regarding the medication's side effects? Select all that apply.
- A. Diarrhea may be a problem for me.
- B. I'll most likely develop high blood pressure.
- C. Being too nervous is a side effect of my medicine.
- D. I will need to watch what I eat so I won't gain weight.
- E. Getting up too quickly when I'm sitting can make me dizzy.
- F. I will need to be careful driving because this can make me drowsy.
Correct Answer: A,B
Rationale: Constipation, not diarrhea, and hypotension, not hypertension, are side effects of risperidone, indicating a need for further education.
The client is being treated with Clozapine. Which findings during the nurse's assessment indicate that the client is experiencing adverse effects of Clozapine? Select all that apply.
- A. Dehydration
- B. Agranulocytosis
- C. Increasing anxiety
- D. Extreme salivation
- E. Blood glucose 192 mg/dL
Correct Answer: B,D,E
Rationale: Agranulocytosis, hypersalivation, and hyperglycemia are adverse effects of clozapine (Clozaril).