A client has been admitted to a psychiatric mental health facility in a manic state. The client's spouse accompanies the client to the facility and informs the nurse that the client has been displaying manic symptoms for the past 2 weeks. The spouse reports that the client has not slept for the past 2 days, and that the client has not eaten anything for at least 3 days.

Which would be the priority nursing diagnosis for this client?

Ineffective health maintenance

Risk for other-directed violence

Risk for imbalanced nutrition

Risk for suicide

Answer and Explanation

The Correct Answer is C

A) Incorrect. While the client's sleep disturbance and lack of selfcare may contribute to
ineffective health maintenance, the more immediate concern is addressing the risk of imbalanced nutrition.

B) Incorrect. While clients in a manic state may exhibit hyperactivity and impulsivity, there is no indication in the scenario that the client poses an immediate risk for other-directed violence.

C) Correct. The client's reported lack of sleep and refusal to eat for an extended period raises concerns about nutritional deficits and dehydration. This is the most immediate and pressing issue to address.

D) Incorrect. While the client's manic state may increase the risk of impulsive behavior, there is no specific indication in the scenario that the client is at immediate risk for suicide.

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Correct Answer is ["B","C","D"]

Explanation

A) Incorrect. While it's important to avoid dehydration, this option is not specific to lithium use.

B) Correct. Lithium can cause dehydration, so it's crucial for the client to drink adequate fluids daily.

C) Correct. A low sodium diet is important while taking lithium, as high sodium levels can affect lithium absorption and potentially lead to toxicity.

D) Correct. Routine blood work is necessary to monitor lithium levels and ensure the client's levels remain within the therapeutic range.

E) Incorrect. Dependency is not a common concern with lithium.

A. Sedation and muscle stiffness B. Sweating, nausea, and diarrhea C. Mild fever, sore throat, and skin rash D. Headache, watery eyes, and runny nose

Correct Answer is A

Explanation

A) Correct. Haloperidol, a first-generation antipsychotic, commonly causes side effects like sedation (drowsiness) and extrapyramidal symptoms, including muscle stiffness.

B) Incorrect. Sweating, nausea, and diarrhea are not typically associated with haloperidol.
C) Incorrect. Mild fever, sore throat, and skin rash are not common side effects of haloperidol.
D) Incorrect. Headache, watery eyes, and runny nose are not common side effects of haloperidol.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. What information should be included in the teaching? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

When a client diagnosed with schizophrenia was discharged 6 months ago, haloperidol was prescribed. The client now says, "I stopped taking those pills. They made me feel like a robot." What are common side effects the nurse should validate with the client?

Correct Answer is A

Explanation

A client asks the nurse to give her information regarding the detoxification process of alprazolam. What is the best response by the nurse?

During the admission process, an elderly client is asked to present their license for identification purposes. The client gives the admission personnel their glasses. This is an example of which of the following symptoms of dementia?

The nurse is caring for a client with poor self-esteem. What intervention would be important for the nurse to include in the plan of care?

The nurse is caring for a client who is withdrawing from long-term use of opioids. The nurse will monitor using a Clinical Opioid Withdrawal Scale (COWS). Which of the following cluster of symptoms would indicate to the nurse the client was withdrawing from opioids?

A physician has prescribed an antidepressant medication for a 15yearold client. Which statement would be appropriate for inclusion in medication teaching?

A client is admitted to the hospital for alcohol intoxication. The family reports that he is a heavy drinker and has been admitted several times for alcohol detoxification. When can the nurse expect to observe the first symptoms of withdrawal?

A client has been diagnosed with major depression and placed on amitriptyline. Which is a side effect of amitriptyline?

An older adult in the middle and late stages of Alzheimer's forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the client's family?