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A client with major depressive disorder is prescribed lithium carbonate. Which finding should the RN report to the healthcare provider?
- A. Serum lithium level of 0.8 mEq/L
- B. Blood urea nitrogen (BUN) level of 16 mg/dL
- C. Serum sodium level of 138 mEq/L
- D. Urine output of 800 mL in 24 hours
Correct Answer: B
Rationale: The correct answer is B: Blood urea nitrogen (BUN) level of 16 mg/dL. This finding should be reported as it may indicate potential renal impairment, a common side effect of lithium carbonate. Elevated BUN levels can suggest decreased kidney function, which can lead to lithium toxicity.
A: A serum lithium level of 0.8 mEq/L is within the therapeutic range for lithium carbonate.
C: A serum sodium level of 138 mEq/L is within the normal range and not a concerning finding.
D: Urine output of 800 mL in 24 hours is a normal amount and not indicative of any immediate concerns related to lithium therapy.
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The nurse leading a group session of adolescent clients gives the members a handout about anger management. One of the male clients is fidgety, interrupts peers when they try to talk, and talks about his pets at home. What nursing action is best for the nurse to take?
- A. Give the client permission to leave and return in 10 minutes.
- B. Explore the client’s feelings about his pets and home life.
- C. Encourage his peers to help involve him in the activity.
- D. Redirect him by encouraging him to read from the handout.
Correct Answer: D
Rationale: The correct answer is D: Redirect him by encouraging him to read from the handout. This option addresses the client's behavior by redirecting his focus back to the group activity. By encouraging him to read from the handout, the nurse provides a constructive way for the client to engage with the material and participate in the session. This approach helps the client stay on track with the intended purpose of the group session, which is anger management.
Other choices are incorrect:
A: Giving the client permission to leave may reinforce disruptive behavior.
B: Exploring the client's feelings about his pets may not address the immediate issue of his behavior.
C: Involving peers may not effectively address the client's disruptive behavior.
Overall, option D is the most appropriate as it directly addresses the client's behavior and redirects him in a positive way.
Carolina is surprised when her patient does not show for a regularly scheduled appointment. When contacted, the patient states, 'I don’t need to come see you anymore. I have found a therapy app on my phone that I love.' How should Carolina respond to this news?
- A. That sounds exciting, would you be willing to visit and show me the app?
- B. At this time, there is no real evidence that the app can replace our therapy.
- C. I am not sure that is a good idea right now, we are so close to progress.
- D. Why would you think that is a better option than meeting with me?
Correct Answer: A
Rationale: Rationale for Choice A: Carolina should respond positively to the patient's enthusiasm about the therapy app to maintain rapport. By asking the patient to show the app, Carolina displays genuine interest and open-mindedness, fostering a collaborative discussion. This approach allows Carolina to understand the patient's perspective and potentially integrate the app into the therapy if suitable. It also shows respect for the patient's autonomy in seeking alternative support.
Summary of other choices:
B: This response is dismissive and does not acknowledge the patient's preferences, potentially damaging the therapeutic relationship.
C: This response may come off as controlling or resistant, risking alienating the patient and hindering progress.
D: This response is confrontational and may make the patient defensive, leading to communication breakdown rather than exploration of alternatives.
A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?
- A. Place in a side-lying position with head of bed elevated.
- B. Administer disulfiram (Antabuse) immediately
- C. Give lorazepam (Ativan) PRN for signs of withdrawal.
- D. Provide thiamine and folate supplements as prescribed.
Correct Answer: A
Rationale: The correct answer is A: Place in a side-lying position with head of bed elevated. This is the priority intervention because the client is difficult to arouse, indicating potential risk for airway compromise and aspiration due to the head injury and elevated BAL. Placing the client in a side-lying position with the head of the bed elevated helps prevent aspiration and promotes optimal airway management. Administering disulfiram (choice B) is not indicated as the priority intervention in this acute situation. Giving lorazepam (choice C) for signs of withdrawal may further depress the client's level of consciousness and is not the priority at this time. Providing thiamine and folate supplements (choice D) is important for alcohol-related deficiencies but does not address the immediate risk of airway compromise.
A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement?
- A. Isolate the client from the other clients.
- B. Administer PRN sedative.
- C. Avoid recognizing the behavior.
- D. Escort the client to his room.
Correct Answer: C
Rationale: The correct answer is C: Avoid recognizing the behavior. Echolalia is the repetition of words or phrases spoken by others, common in schizophrenia. By not reinforcing or acknowledging the behavior, the client may eventually stop. Isolating the client (Choice A) may lead to feelings of rejection. Administering a sedative (Choice B) may not address the underlying behavior. Escorting the client to his room (Choice D) does not address the echolalia directly.
A nurse is caring for a client who was admitted for alcohol disorder. which one of the following require follow uo by the nurse? select all that apply
- A. Cardiac assessment
- B. Smoking history
- C. Genitourinary assessment
- D. Neurological assessment
- F. Client's recent loss
- G. Gastrointestinal assess,ment
Correct Answer: B
Rationale: The correct answer is B: Smoking history. This requires follow-up by the nurse because smoking can exacerbate alcohol-related health issues. The nurse needs to assess smoking habits to provide comprehensive care and address potential risks.
A: Cardiac assessment is important but not specifically related to alcohol disorder.
C: Genitourinary assessment may be important but is not a priority in this case.
D: Neurological assessment is crucial in alcohol disorder but is not the focus of the question.
F: Client's recent loss is important but not directly related to the client's alcohol disorder.
G: Gastrointestinal assessment is relevant but not a priority in this scenario.