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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 C

Explanation

Choice A rationale:
Obesity is a modifiable risk factor for stroke, as it can be controlled through diet and exercise.
Choice B rationale:
History of hypertension is also a modifiable risk factor, as it can be managed with medication and lifestyle changes.
Choice C rationale:
Genetics is a nonmodifiable risk factor for stroke, as individuals cannot change their genetic makeup.
Choice D rationale:
History of smoking is a modifiable risk factor, as individuals can choose to quit smoking.

Correct Answer is B

Explanation

Choice A rationale:
Placing the client back in bed during a seizure could lead to injury.
Choice B rationale:
Placing the client on his side, specifically the left side, allows for the tongue to fall forward, preventing aspiration.
Choice C rationale:
Holding the client’s arms and legs from moving could cause harm to the client or nurse.
Choice D rationale:
Inserting a tongue blade in the client’s mouth could cause injury to the client’s oral cavity.

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