Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a client who has bipolar disorder.

Exhibits

Which of the following assessment findings require immediate follow- up? (Select all that apply.)

Blood pressure

Lithium level

Sodium level

WBC count

Thyroid-stimulating (TSH) level

BUN level

Levothyroxine dosage

Acetaminophen

Lithium dosage

Answer and Explanation

Correct Answer : B,C,F,I

A. Blood pressure – Within normal range (115/76 mm Hg). No immediate concern.
B. Lithium level – 1.7 mEq/L is above the therapeutic range (0.8–1.2). Toxicity is likely, especially with the client’s symptoms (tremor, confusion, GI upset). Requires urgent follow-up.
C. Sodium level – 128 mEq/L indicates hyponatremia. Low sodium increases the risk for lithium toxicity because lithium and sodium compete for renal reabsorption.
D. WBC count – Within normal range (7,000/mm³).
E. TSH level – Mildly elevated (6). Suggests hypothyroidism (a side effect of lithium) but not immediately life-threatening. Requires follow-up, but not urgent.
F. BUN level –Elevated at 30 mg/dL (normal 10–20). Indicates impaired renal function, which reduces lithium clearance and increases toxicity risk.
G. Levothyroxine dosage – No immediate safety issue noted; managed long term.
H. Acetaminophen – Daily 325 mg is safe; not a concern.
I. Lithium dosage – Current dose (600 mg BID) is likely contributing to toxicity and must be reassessed immediately.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Justice refers to fairness and equality in the distribution of care and resources. The nurse is concerned about whether patients exhibiting similar behaviors (self-mutilation) are being treated consistently and fairly, which directly relates to the principle of justice.

B. Fidelity involves keeping promises and commitments to patients, which is not the primary concern in this scenario.
C. Beneficence involves acting in the patient’s best interest to promote well-being. While relevant to care decisions, the main ethical issue here is fairness between patients.
D. Autonomy involves respecting a patient’s right to make their own decisions, which is not the central issue in comparing the care of two patients.

A. Countertransference B. Catastrophic reaction C. Defensive coping reaction D. Transference

Correct Answer is A

Explanation

A. This occurs when the nurse projects personal feelings about someone from their own life onto the patient (e.g., comparing the patient to a grandparent and feeling sadness).

B. This refers to severe emotional outbursts in cognitively impaired patients, not nurse behavior.

C. This would involve the nurse using defense mechanisms to protect themselves from anxiety, not relating to the patient as a grandparent.

D. Transference is when the patient projects feelings onto the nurse, not the other way around.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who has bipolar disorder. Exhibits Which of the following assessment findings require immediate follow- up? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse assesses a confused older adult. The nurse experiences sadness and reflects. This patient is like one of my grandparents... so helpless." Which response is the nurse demonstrating?

Correct Answer is A

Explanation

A patient diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate?

Which action by a psychiatric nurse best applies the ethical principle of autonomy?

A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating?

A nurse in an emergency department is caring for a client who is experiencing acute alcohol withdrawal. Which of the following actions should the nurse first take?

An older adult diagnosed with dementia lives with family in a rural area. During the week, this adult attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this adult most vulnerable to abuse?

A nurse is providing teaching for a client who has major depressive disorder and is seeking voluntary admission to an acute mental health facility. Which of the following statements should the nurse include?

A nurse has prepared teaching materials for the parents of a child newly diagnosed with ADHD. The information will focus on which medication likely to be prescribed?

A cruel and abusive person often uses rationalization to explain their behavior. Which comment demonstrates use of this defense mechanism?

A nurse is caring for a client who has bipolar disorder.

Exhibits

Which of the following assessment findings require immediate follow- up? (Select all that apply.)