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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 D

Explanation

Choice A rationale:
This statement is incorrect. Impulsive behavior is more commonly associated with right hemispheric CVAs.
Choice B rationale:
This statement is incorrect. A left hemispheric CVA typically results in right-side motor function impairment.
Choice C rationale:
This statement is incorrect. Loss of depth perception is more commonly associated with right hemispheric CVAs.
Choice D rationale:
This statement is correct. Left hemispheric CVAs often result in language and speech impairments, so establishing effective communication would be a key goal in rehabilitation.

Correct Answer is C

Explanation

Choice A rationale:
This statement is incorrect. Movement can distort the image quality in an MRI scan, so patients are usually asked to lie still.
Choice B rationale:
This statement is incorrect. MRI contrast dye does not contain iodine, and it is less likely to cause an allergic reaction.
Choice C rationale:
This statement is correct. MRI scans can be very noisy due to the magnetic fields changing during the scan. Patients are often offered earplugs or headphones to reduce the noise.
Choice D rationale:
This statement is incorrect. The length of an MRI scan can vary, but it often takes longer than 30 minutes.

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