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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:
Indwelling urinary catheters can actually increase the risk of UTIs.
Choice B rationale:
Offering the bedpan every 2 hours may not be necessary or practical for all patients.
Choice C rationale:
Cleaning the perineum from back to front can introduce bacteria to the urinary tract, increasing UTI risk.
Choice D rationale:
Adequate hydration can help flush bacteria out of the urinary tract, reducing UTI risk.

Correct Answer is []

Explanation

Condition Most Likely Experiencing:

Delirium

  • Explanation: The client has acute confusion, disorganized thinking, restlessness, incoherent speech, and altered sleep-wake cycle—all classic signs of delirium. The sudden onset (starting the previous evening) and fever (38.6°C) suggest a potential underlying cause, such as infection or dehydration.

Actions to Take:

Monitor the client's fluid intake and output.

  • Explanation: The client has severe fluid imbalance (250 mL intake vs. 2,500 mL output), leading to dehydration, which can contribute to delirium. Monitoring intake and output is critical for managing hydration status.

Encourage family members to stay with the client.

  • Explanation: Familiar faces can help reorient the client and reduce agitation. Delirium often improves with familiar environmental cues and reassurance.

Parameters to Monitor:

Sleep-wake cycle.

  • Explanation: Disrupted sleep patterns are a key symptom of delirium. Tracking sleep can help assess improvement or worsening of the condition.

Fall risk.

  • Explanation: The client is attempting to get out of bed without assistance, which puts them at high risk for falls. Close monitoring is essential to prevent injury.

Incorrect Choices and Explanations:

Request a prescription for benzodiazepine.

  • Why Incorrect? Benzodiazepines can worsen delirium, especially in older adults, by increasing confusion and fall risk.

Assist the client to identify coping skills.

  • Why Incorrect? Delirium is an acute medical condition, not a psychological disorder. The focus should be on treating the underlying cause, not psychological coping strategies.

Encourage the client to exercise.

  • Why Incorrect? The client is confused, weak, and at risk of falls. Exercise is not appropriate at this stage.

BUN level.

  • Why Incorrect? While kidney function (BUN) could be affected by dehydration, monitoring fluid balance directly (intake/output) is more immediate and relevant.

Weight loss.

  • Why Incorrect? While the client has refused to eat or drink, weight loss occurs over time, whereas the primary concern is acute dehydration and delirium.

Suicidal ideation.

  • Why Incorrect? There is no indication of suicidal thoughts. The confusion and agitation are more likely due to delirium than depression.

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