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.

Vision

Lithium level

Urine output

Mucous membranes

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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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:
Difficulty reading is not typically associated with right hemisphere strokes.
Choice B rationale:
Aphasia, or difficulty with language, is a common symptom of right hemisphere strokes.
Choice C rationale:
Inability to recognize family members is not typically a symptom of right hemisphere strokes.
Choice D rationale:
Right hemiparesis, or weakness on the right side of the body, is typically associated with left hemisphere strokes, not right.

A. "I will take one aspirin every day.”. B. "I will closely follow a high-purine diet.”. C. "I will limit my fluid intake to 1 liter per day.”. D. "I will limit my alcohol intake.”.

Correct Answer is D

Explanation

Choice A rationale:
Aspirin is not typically recommended for gout due to its potential to elevate uric acid levels.
Choice B rationale:
A high-purine diet can exacerbate gout symptoms, so this statement is incorrect.
Choice C rationale:
Limiting fluid intake can lead to dehydration, which can trigger a gout attack.
Choice D rationale:
Alcohol, especially beer, can increase uric acid levels and trigger gout attacks, so limiting alcohol intake is recommended.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

Correct Answer is B

Explanation

A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen?

Correct Answer is D

Explanation

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