Nokea
Which observation(s) is helpful in determining a client's mood? Select all that apply.
- A. Client appearance
- B. Body language
- C. Speech
- D. Energy level
- E. Work history
Correct Answer: A,B,C,D
Rationale: The nurse can gather observational data using the assessment skill of inspection. Client appearance that is disheveled indicates signs of personal neglect. Body language may indicate evidence of anxiety, anger, or depression. Pace of speaking and energy level indicates mania or depression. Work history can be helpful in determining information related to a client's ability to fit in socially but is not included in observational data.
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The nurse is completing a plan of care for a client on lithium therapy to manage bipolar symptoms. Which nursing intervention(s) will be included? Select all that apply.
- A. Monitor for symptoms of nausea, vomiting, muscle weakness, and lack of coordination.
- B. Increase fluid intake to 5000 mL/day.
- C. Limit sodium intake daily.
- D. Monitor kidney and liver functioning.
- E. Instruct client that it may take up to 6 weeks to reach therapeutic level.
- F. Monitor intake and output.
Correct Answer: A,B,D,F
Rationale: The nurse is correct to place in the plan of care interventions that include monitoring for symptoms of lithium toxicity, increasing fluid intake to maintain fluid balance, monitoring kidney and liver function, and monitoring intake and output. Salt intake is important to regulate lithium levels in the body. A therapeutic lithium level is accomplished in a few days to a week.
The nurse is caring for a middle-aged client prescribed a selective serotonin reuptake inhibitor (SSRI). Which side effect of medication therapy leads to the most common cause of noncompliance?
- A. Hypertension
- B. Dizziness
- C. Hallucinations
- D. Sexual dysfunction
Correct Answer: D
Rationale: When taking a selective serotonin reuptake inhibitor, the nurse must instruct on the most common side effect, which is sexual dysfunction. Unfortunately, sexual dysfunction (reduced desire for sex, erectile and ejaculatory dysfunction, and the inability to orgasm) is a frequent and undesirable side effect that leads to noncompliance in medication regimen. The other side effects are not associated with use of SSRIs.
The nurse is providing teaching to a client starting monoamine oxidase inhibitor (MAOI) drug therapy. Which over-the-counter medications should the nurse instruct the client to avoid?
- A. Cold and allergy medications
- B. Antiulcer medications
- C. Multivitamins
- D. Laxatives
Correct Answer: A
Rationale: The nurse is correct to place cold and allergy medications on a clinical reference guide of over-the-counter medications to avoid. These preparations may have a drug-drug interaction. The client can use over-the-counter antiulcer medications, multivitamins, and laxatives per physician instruction.
Administering an MAOI with food containing tyramine may develop a potentially fatal condition known as which of the following?
- A. Psychosis
- B. Serotonin syndrome
- C. Hypertensive crisis
- D. Hallucinations
Correct Answer: C
Rationale: When a MAOI is combined with foods containing tyramine, another monoamine, clients are likely to develop a potentially fatal hypertensive crisis, with symptoms such as elevated blood pressure and palpitations.
The nurse is caring for an older adult client diagnosed with bipolar disorder. Which manifestation of the disease can the nurse anticipate?
- A. The disease remits as the client ages.
- B. The disease increases as the client ages.
- C. The depression increases as the client ages.
- D. The manic phase increases as the client ages.
Correct Answer: C
Rationale: Older adult clients with bipolar disorder typically experience depressive episodes that increase in frequency and last longer. The increase for functional decline occurs, which may necessitate further care.