A nurse is admitting a client to the mental health unit.
The nurse is developing a plan of care for the client. Which of the following interventions should the nurse include? (Select all that apply.)
Notify the provider of potential medication interactions.
Discuss contraception with the client.
Set up a dietary consult for a low-sodium diet.
Educate the client about the need for hemodialysis.
Administer prochlorperazine.
Withhold next dose of lithium.
Correct Answer : A,E,F
A. Notify the provider of potential medication interactions: Furosemide, a loop diuretic, and NSAIDs like ibuprofen can increase lithium levels, contributing to toxicity. Notifying the provider is essential to reassess the medication regimen, especially with current signs of toxicity.
B. Discuss contraception with the client: There is no indication in the scenario that contraception counseling is an immediate priority or concern for this client at this time.
C. Set up a dietary consult for a low-sodium diet: Low-sodium diets can increase lithium reabsorption, worsening lithium toxicity. In fact, the client has hyponatremia (Na+ 131) already, so a low-sodium diet is contraindicated.
D. Educate the client about the need for hemodialysis: While hemodialysis may be required in severe lithium toxicity, this decision should be made by the provider. The nurse should monitor and report symptoms but not initiate education about dialysis unless prescribed.
E. Administer prochlorperazine: This is appropriate PRN medication for nausea and vomiting, which are symptoms of lithium toxicity and are present in this client.
F. Withhold next dose of lithium: The client’s current lithium level (2.2 mEq/L) is above the toxic range (>2.0 mEq/L). Continuing lithium could worsen toxicity, so the nurse should withhold the next dose and notify the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The gallbladder has become inflamed due to the cholesterol in the gallstones. While cholesterol is a common component of gallstones, the problem is not just inflammation due to cholesterol itself. Gallstones can cause inflammation (cholecystitis) when they block the bile ducts, leading to pain and potential infection, not just due to cholesterol buildup alone.
B. The gallbladder became infected by a virus and needs to be removed. This statement is not accurate because gallstones typically cause inflammation (cholecystitis) when they obstruct bile flow, not due to a viral infection. The infection typically results from the obstruction of bile flow by the stones, leading to bacterial growth, not a viral cause.
C. The gallbladder has become blocked by a tumor and is no longer working. While tumors in the bile ducts can cause similar symptoms, the most common cause for gallbladder removal (cholecystectomy) is the presence of gallstones, not a tumor. Gallstones can block bile flow, causing inflammation and requiring surgical removal.
D. The gallbladder has become inflamed due to a build-up of gallstones that are blocking the common bile duct. This is the correct explanation. Gallstones can form in the gallbladder and, when they block the common bile duct, they can cause inflammation (cholecystitis), pain, and sometimes infection. This blockage can impair bile flow, leading to symptoms like nausea, vomiting, and jaundice. This is the typical reason for needing a cholecystectomy.
Correct Answer is ["A","D","E","F"]
Explanation
Rationale for Correct Options:
Experience with legal system since teenage years: Repeated arrests and juvenile detention are key indicators of early conduct disorder, a precursor to ASPD.
Relationship with family: Estrangement and lack of meaningful interpersonal relationships reflect disregard for social bonds, common in ASPD.
Acceptance of responsibility: People with ASPD often blame others or deny responsibility for their actions.
Substance use: Common comorbidity; often related to impulsivity, risk-taking, and disregard for legal/social norms.
Rationale for Incorrect Options:
Adhering to financial responsibilities: Clients with ASPD often do not meet financial obligations (in this case, the client was evicted for nonpayment).
Employment status: While the client is employed, people with ASPD may have unstable work histories; this alone is not diagnostic.
Compassion toward others: A lack of empathy and compassion is a hallmark of ASPD.
Rechanneling anger with physical activity: This reflects healthy coping, which is not typical in ASPD unless it is manipulative or self-serving.
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