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A nurse is caring for a client.

Exhibits

The nurse is collecting data from the client 12 hr later.

How should the nurse interpret the following findings?

For each potential finding, click to specify whether the finding is an indication of potential improvement or an indication of potential worsening condition.

A.

Vision

B.

Lithium level

C.

Urine output

D.

Mucous membranes

E.

Vital signs

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

  • Vision (Blurred)

    • Interpretation: Potential worsening condition
    • Rationale: Blurred vision can be a sign of lithium toxicity. Despite the lithium level improving, this symptom indicates that neurotoxicity may still be present.

  • Lithium Level (1.2 mEq/L)

    • Interpretation: Potential improvement
    • Rationale: The lithium level has decreased from 1.8 mEq/L (toxic) to 1.2 mEq/L, which is within the therapeutic range (0.6-1.2 mEq/L). This indicates that treatment to lower lithium toxicity is effective.

  • Urine Output (40 mL/hr)

    • Interpretation: Potential improvement
    • Rationale: A urine output of 40 mL/hr is within the acceptable range (normal is greater than 30 mL/hr), suggesting that kidney function is adequate and not compromised by lithium toxicity.

  • Mucous Membranes (Pale, Dry)

    • Interpretation: Potential worsening condition
    • Rationale: Pale, dry mucous membranes suggest dehydration, which can increase the risk of lithium toxicity and negatively affect overall health.

  • Vital Signs (BP 88/50 mm Hg, Pulse 96/min)

    • Interpretation: Potential worsening condition
    • Rationale: The drop in blood pressure from 130/84 mm Hg to 88/50 mm Hg indicates hypotension. This could be related to dehydration or lithium toxicity, and it requires follow-up as the condition is deteriorating.


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Related Questions

Correct Answer is A

Explanation

Choice A rationale:
Increasing fluid intake can help replace cerebrospinal fluid lost during a lumbar puncture, which can alleviate a post-lumbar puncture headache.
Choice B rationale:
Elevating the head of the bed can actually worsen a post-lumbar puncture headache by increasing the loss of cerebrospinal fluid.
Choice C rationale:
While pain medication can provide temporary relief, it does not address the underlying cause of the headache.
Choice D rationale:
Darkening the room and closing the door can help reduce sensory stimulation, but it does not directly address the cause of the headache.

Correct Answer is B

Explanation

Choice A rationale:
Flexing her ankles is a safe action that promotes blood flow and prevents clot formation.
Choice B rationale:
Massaging her legs can dislodge a clot if one has formed, leading to a VTE.
Choice C rationale:
Elevating her feet improves venous return, reducing the risk of VTE.
Choice D rationale:
Ambulating soon after surgery promotes blood flow and prevents clot formation.

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