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. Five-pound (2.3 kg) weight gain.
- B. Nausea and vomiting.
- C. Short-term memory loss.
- D. Depressed affect.
Correct Answer: B
Rationale: Nausea and vomiting may indicate lithium toxicity, requiring immediate reporting. Other symptoms are concerning but less urgent.
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Nurse Notes
0900
Pain assessment completed. The client's pain is 2/10. The client requests sleeping medication for the night. She states that she has horrible thoughts and memories about the house collapsing all the time and that it is keeping her from falling asleep. She states, "I used to be so happy before all of this happened. Now I can't seem to get out of this funk I am in." The client would also prefer to be in a quieter area of the unit as she is currently by the nurses' station and hears talking and alarms constantly.
1100
The nurse reviews the physician's orders for clonazepam and gives the medication as ordered.
1115
Start clonazepam 0.25 mg PO every 12 hours
What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.
- A. Assist the client to the bathroom
- B. Assess mental status regularly
- C. Provide oral care at least twice a day
- D. Screen for orthostatic hypotension
- E. Monitor calcium levels
- F. Have an opioid agonist at the bedside
Correct Answer: B,C,D
Rationale: Assessing mental status, providing oral care, and screening for orthostatic hypotension are appropriate for clonazepam's CNS effects and side effects like dry mouth. Bathroom assistance, calcium monitoring, and opioid agonists are irrelevant.
Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?
- A. Any history of heart disease.
- B. Familial history of mental illness.
- C. Current weight.
- D. Medication history.
Correct Answer: D
Rationale: Medication history is critical to identify potential drug interactions, especially with serotonergic drugs, to prevent serotonin syndrome. Heart disease history, familial mental illness, and weight are relevant but secondary. [Note: Document incorrectly lists A as correct; D is more appropriate per standard practice.]
The nurse plans to use role-playing as a therapeutic measure. Which individual is most likely to benefit from this type of therapeutic intervention?
- A. An adult with schizophrenia who often refuses to take prescribed antipsychotic medications.
- B. A hyperactive 4-year-old who has recently been tested for autism.
- C. An older adult resident of a long-term care facility who sometimes takes other residents' belongings.
- D. An adolescent who is depressed over not being accepted by peers.
Correct Answer: D
Rationale: Role-playing helps adolescents practice social skills and coping strategies for peer rejection, making it most effective for this group.
A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?
- A. Assist the client with relaxation techniques in the group.
- B. Escort the client from the group to reduce stimuli.
- C. Provide education about ways to cope with anxiety.
- D. Ask the client to describe and identify the source of the feelings.
Correct Answer: A
Rationale: Assisting with relaxation techniques in the group provides immediate anxiety relief and support, suitable for acute anxiety.
History and Physical
Nurse's Notes
Orders
The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration.
For each client statement, click to highlight the statement(s) below that require follow-up teaching by the nurse.
- A. This diagnosis means that I am crazy.'
- B. I can learn to manage my thoughts better through therapy.'
- C. I can use holistic approaches like meditation to help my symptoms.'
- D. Many people have the same response to a stressful situation as I am having right'
- E. I am at high risk for post-traumatic-stress disorder because I have acute stress disorder'
- F. I will probably need to be on medication for the rest of my life.'
Correct Answer: A,C,D,F
Rationale: Statements about being 'crazy,' typical stress responses, holistic approaches, and lifelong medication need clarification to address stigma, variability in trauma responses, and treatment plans.