Nokea
The nurse is caring for a client with a history of bipolar disorder who is receiving lithium 300 mg PO tid. Which of the following symptoms should the nurse report immediately?
- A. Mild thirst.
- B. Tremors and confusion.
- C. Occasional diarrhea.
- D. Dry mouth.
Correct Answer: B
Rationale: Tremors and confusion suggest lithium toxicity, a medical emergency. Options A, C, and D are common side effects.
You may also like to solve these questions
An extremely angry patient with bipolar illness who just learned his wife has filed for divorce.
Which of the following responses by the nurse is MOST appropriate?
- A. Allow the patient to use the phone.
- B. Confront the patient about his anger and inappropriate plan of action.
- C. Do not allow the patient to use the phone because he is an involuntary patient.
- D. Set limits on the patient's phone use because he has been unable to control his behavior.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-patient is able to use phone unless otherwise indicated by court order or physician's order (2) has not lost civil right to use phone (3) denies patient his civil rights (4) inappropriate
The mother of a 3-month-old infant tells the nurse that her child has a bumpy rash over most of his body. What is likely to be initially ordered for this child?
- A. Skin biopsy
- B. Stool specimen
- C. CBC with differential
- D. Elimination diet
Correct Answer: D
Rationale: A bumpy rash in a 3-month-old suggests possible food allergies; an elimination diet is a non-invasive initial approach to identify triggers, unlike biopsy, stool, or CBC.
The nurse is performing hypertension screening at the local grocery store. It would be MOST important for the nurse to complete which of the following tasks?
- A. Use a blood pressure cuff that overlaps the arm at least four inches.
- B. Support the client's arm above the level of the heart.
- C. Take two readings at least five minutes apart.
- D. Take the blood pressure after the client has exercised for 10 minutes.
Correct Answer: C
Rationale: Two readings five minutes apart ensure accuracy in hypertension screening. Options A, B, and D are incorrect techniques.
The nurse checks for placement of a nasogastric (NG) tube before beginning a tube feeding for a client.
Which of the following results would indicate to the nurse that the tube feeding can begin?
- A. A small amount of white mucus is aspirated from the NG tube.
- B. The pH of the contents removed from the NG tube is 3.
- C. No bubbles are seen when the nurse inverts the NG tube in water.
- D. The client says he can feel the NG tube in the back of his throat.
Correct Answer: B
Rationale: Strategy: Determine how the answers relate to a tube feeding. (1) mucus may be from lungs (2) correct-stomach contents are acidic (3) not a safe way to check placement (4) not a reliable indication
Which of the following findings is consistent with a diagnosis of congestive heart failure?
- A. Jugular vein distention indicates increased fluid volume
- B. Carbon dioxide reading of 30
- C. Hemoglobin of 18
- D. Potassium level of 5.5
Correct Answer: A
Rationale: Jugular vein distention reflects increased fluid volume and right-sided heart failure, a hallmark of congestive heart failure. Other options are not specific to this condition.