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 laboratory results would be of GREATest concern to the nurse?
- A. Lithium level of 2.0 mEq/L.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Creatinine 1.0 mg/dL.
Correct Answer: A
Rationale: A lithium level of 2.0 mEq/L is toxic (therapeutic range 0.6–1.2 mEq/L), risking seizures or coma, requiring immediate intervention. Options B, C, and D are normal: sodium 140 mEq/L, potassium 4.0 mEq/L, and creatinine 1.0 mg/dL do not indicate complications.
You may also like to solve these questions
The nurse is caring for a client with a new colostomy. Which of the following client statements indicates a need for further teaching?
- A. I should change the pouch when it’s about one-third full.
- B. I should empty the pouch every morning.
- C. I should eat a high-fiber diet to prevent constipation.
- D. I should check the skin around the stoma for irritation.
Correct Answer: B
Rationale: Emptying the pouch every morning is a rigid schedule that does not account for individual bowel patterns; it should be emptied when one-third to one-half full. Options A, C, and D are correct: changing when one-third full prevents leaks, high-fiber diets promote regularity, and skin checks prevent breakdown.
A patient several days after an above-knee amputation (AKA).
Which of the following symptoms would be characteristic of an infected stump wound?
- A. The patient is anxious and restless.
- B. There is a small amount of dark drainage on the dressing.
- C. The patient complains of persistent pain at the operative site.
- D. The skin is cool above the operative site.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to an infected wound. (1) may be due to changes in body image or pain (2) expected, not indicative of an infection (3) correct-pain is characteristic of inflammation and infection (4) warm skin above site would indicate infection
A 3 year-old child is brought to the clinic by his grandmother to be seen for 'scratching his bottom and wetting the bed at night.' Based on these complaints, the nurse would initially assess for which problem?
- A. allergies
- B. scabies
- C. regression
- D. pinworms
Correct Answer: D
Rationale: Pinworms are a common cause of anal itching and can contribute to bed-wetting in children due to discomfort. The nurse should assess for signs of pinworm infection, such as observing the anal area for worms or performing a tape test.
A client tells the nurse he is fearful of planned surgery because of evil thoughts about a family member. What is the best initial response by the nurse?
- A. Call a chaplain
- B. Deny the feelings
- C. Cite recovery statistics
- D. Listen to the client
Correct Answer: D
Rationale: Listen to the client. Therapeutic communications are based on attentive listening to expressed feelings, followed by questions about cultural beliefs if needed.
A client who is withdrawing from alcohol says to the nurse, 'There are snakes on the wall.' Which action should the nurse take initially?
- A. Reassure the client that there are no snakes
- B. Turn the lights on brighter
- C. Tell the client that while he may see snakes, there are really no snakes
- D. Reassure the client that the snakes will not hurt him
Correct Answer: C
Rationale: Acknowledging the hallucination (delirium tremens) as perceived but clarifying reality reduces agitation without confrontation. Reassurance or lighting changes are less effective.