A nurse is caring for a client.

The nurse is assessing the client. Select the 4 findings that require immediate follow-up.

Heart rate

Hallucinations

Sleep pattern

Skin turgor

Hygiene

Answer and Explanation

Correct Answer : A,B,C,D

A. Heart rate: A heart rate of 120/min is tachycardic and may indicate physiological stress, dehydration, or other medical complications. Immediate follow-up is necessary to assess underlying causes and prevent further cardiovascular compromise.

B. Hallucinations: The client is responding to unseen stimuli, which suggests possible psychosis or severe mania. Hallucinations pose a safety risk to the client and others and require urgent psychiatric and medical evaluation.

C. Sleep pattern: The client has not slept for 2 days, indicating severe sleep deprivation. Sleep loss can exacerbate agitation, impair judgment, and increase the risk of medical and psychiatric complications, making prompt intervention essential.

D. Skin turgor: Poor skin turgor indicates dehydration, which can lead to electrolyte imbalances, hypotension, and other acute complications. Immediate follow-up is needed to initiate fluid replacement and prevent further physiological deterioration.

E. Hygiene: Unclean hair and clothing reflect self-care deficits, but while important for overall well-being, hygiene issues do not require immediate intervention compared with vital signs, safety, and acute physiological concerns.

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Free Nursing Study Resources

Correct Answer is ["A","D","E"]

Explanation

A. "This medication can cause nausea and drowsiness.": Gastrointestinal upset and central nervous system effects such as drowsiness are common early adverse effects of lithium therapy. Clients should be informed so they can recognize mild side effects versus signs of toxicity.

B. "You will be placed on a low-sodium diet while taking this medication.": Lithium requires a consistent, not low, sodium intake. Low sodium can increase lithium reabsorption in the kidneys, raising the risk of toxicity. Emphasizing a consistent dietary sodium intake is important rather than restricting sodium.

C. "Blurred vision is an expected adverse effect of this medication.": Blurred vision is not an expected side effect of lithium and may indicate toxicity or another ocular issue. Clients should report changes in vision promptly rather than consider them routine.

D. "This medication can cause weight gain.": Weight gain is a known side effect of lithium therapy due to fluid retention and metabolic changes. Clients and caregivers should be aware to monitor weight and maintain healthy lifestyle practices.

E. "It will take at least a week before this medication reaches a therapeutic level.": Lithium requires several days to reach a therapeutic blood level, and effects on mood stabilization are gradual. Educating the client about delayed onset helps set realistic expectations and encourages adherence.

A. Take this medication at the same time each day. B. Take ginger for constipation while on this medication. C. Eat foods high in vitamin K. D. Shave with disposable razors.

Correct Answer is A

Explanation

A. Take this medication at the same time each day: Consistent timing helps maintain stable anticoagulation levels and reduces the risk of under- or over-anticoagulation. Warfarin’s effectiveness and safety depend on steady dosing and adherence to a regular schedule.

B. Take ginger for constipation while on this medication: Ginger can increase the risk of bleeding when taken with warfarin due to its antiplatelet properties. Clients should avoid supplements or herbal remedies that may interact with anticoagulants unless approved by the healthcare provider.

C. Eat foods high in vitamin K: Foods high in vitamin K, such as leafy greens, can decrease the effectiveness of warfarin by promoting clotting. Clients should maintain a consistent intake rather than increasing consumption to avoid fluctuations in anticoagulation levels.

D. Shave with disposable razors: Clients on warfarin are advised to use electric razors instead of disposable or manual razors to reduce the risk of cuts and bleeding. Using disposable razors increases the likelihood of minor injuries that can lead to excessive bleeding.

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A nurse is caring for a client. The nurse is assessing the client. Select the 4 findings that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","D","E"]

Explanation

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Correct Answer is A

Explanation

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A nurse is caring for a client.

The nurse is assessing the client. Select the 4 findings that require immediate follow-up.