Nokea
The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?
- A. Nausea and vomiting
- B. Short-term memory loss
- C. Five-pound (2.3 kg) weight gain
- D. Depressed affect
Correct Answer: A
Rationale: Nausea and vomiting could indicate lithium toxicity, requiring immediate attention to prevent serious complications. Memory loss and weight gain are common side effects but less urgent. Depressed affect may relate to the underlying condition but is not immediately life-threatening.
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Nurses' Notes
• Diagnosis: depression and post-traumatic stress disorder Diphenhydramine 12.5 mg PO every night at sleep (HS) • Buspirone hydrochloride 7.5 mg PO twice a day
During the conversation with the client, the nurse documents a statement by the client about wishing she had died in the crash.
During the conversation with the client, the nurse documents a statement by the client about wishing she had died in the crash. The statement by the client represents and should be followed up with an
- A. suicidal ideation, assessment of risk factors for suicide
Correct Answer: A
Rationale: The client's statement reflects suicidal ideation, requiring immediate assessment of suicide risk factors (e.g., history, stressors, support systems) to determine appropriate interventions, ranging from monitoring to psychiatric evaluation.
A nurse is caring for a client:
The client has returned to work at an accounting firm and has started going to a grief support group. She reports she is seeking care from a healthcare professional because her father is worried about her. The client says she only gets 2 to 3 hours of sleep due to nightmares about the crash. She informs that exercising right after work helps her get better sleep and to relax. She feels that she is "jumpy" after the accident, especially when she is in the car. She also stated, "I feel so sad that I can't seem to feel anything at all." In addition to her father, the client has a large family and friend support system. She denies alcohol or drug use.
Click to highlight the areas that the nurse should react to immediately. The client has returned to work at an accounting firm and has started going to a grief support group. She reports she is seeking care from a healthcare provider because her father is worried about her. The client says she only gets 2 to 3 hours of sleep due to nightmares about the crash. She informs that exercising right after work helps her get better sleep and to relax. She feels that she is 'jumpy' after the accident, especially when she is in the car. She also stated, 'I feel so sad that I can't seem to feel anything at all.' In addition to her father, the client has a large family and friend support system. She denies alcohol or drug use.
- A. she only gets 2 to 3 hours of sleep
- B. She feels that she is 'jumpy' after the accident
- C. I feel so sad that I can't seem to feel anything at all
Correct Answer: A,B,C
Rationale: Sleep disturbances, heightened startle response ('jumpy'), and sadness/numbness indicate possible acute stress or PTSD, requiring immediate intervention like creating a safe environment and mental health referral. These symptoms suggest significant distress post-trauma.
In conducting the initial assessment of a preoperative client, the nurse notes that the client's home medications include the monoamine oxidase (MAO) inhibitor phenelzine. Because of this client's medication history, which assessment finding is most important for the nurse to monitor?
- A. Blood pressure
- B. Urinary output
- C. Respiratory rate
- D. Temperature
Correct Answer: A
Rationale: MAO inhibitors like phenelzine can cause hypertensive crises, especially with certain foods or medications. Monitoring blood pressure is critical to detect this life-threatening complication. Urinary output, respiratory rate, and temperature are less directly affected by MAO inhibitors.
The nurse continues to care for the patient
The client is a 19-year-old male who is in the emergency room for a leg injury. He states he was returning to his dorm from a party and fell about 5 feet (1.5 meters) into a small ravine on campus. The client states that he drinks socially and takes no medications for any health condition.
The nurse is listening to the client.
Because the client is a male, he is especially at risk for which psychosocial two sequalae of sexual assault?
- A. Suicide
- B. Depression
- C. Post-traumatic stress disorder
- D. Becoming an abuser
- E. Human immunodeficiency virus
- F. Chlamydia
Correct Answer: B,C
Rationale: B: Depression is common post-sexual assault due to psychological trauma. C: PTSD is frequent, with symptoms like flashbacks and anxiety. A: Suicide is a risk but not male-specific. D: Becoming an abuser is less common. E, F: HIV and chlamydia are physical, not psychosocial, risks.
Mark which behaviors might be related to alcohol intoxication, acute phase of rape-trauma syndrome, or both. Tick only 1 box.
- A. Numbness: Rape-trauma syndrome
- B. Poor decision making: Alcohol intoxication
- C. Crying: Both
- D. Disbelief: Rape-trauma syndrome
- E. Irritability: Alcohol intoxication
- F. Difficulty concentrating: Both
Correct Answer: C
Rationale: Crying occurs in both alcohol intoxication (due to disinhibition) and rape-trauma syndrome (due to emotional distress). Numbness and disbelief are specific to rape-trauma syndrome. Poor decision making, irritability, and difficulty concentrating are typical of alcohol intoxication, though the latter can also occur in rape-trauma syndrome.