A nurse is reviewing a client’s laboratory results prior to administering the client’s medications. The nurse notes that the client’s lithium level is 2.0 mEq/L.
Which of the following findings should the nurse expect?

Muscle irritability.

Constipation.

Hypoglycemia.

Increased BP.

Answer and Explanation

The Correct Answer is A

Muscle irritability. A client with a lithium level of

2.0 mEq/L has severe lithium toxicity, which can cause muscle irritability, tremors, seizures, and other neurological symptoms. The normal therapeutic range for lithium is 0.8-1.2 mEq/L.

Choice B is wrong because constipation is not a sign of lithium toxicity, but rather a possible side effect of lithium therapy at lower doses.

Choice C is wrong because hypoglycemia is not a sign of lithium toxicity, but rather a possible complication of diabetes or other conditions that affect blood sugar levels.

Choice D is wrong because increased blood pressure is not a sign of lithium toxicity, but rather a possible risk factor for cardiovascular disease or other conditions that affect blood vessels.

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Correct Answer is A

Explanation

Coughing while eating after a stroke may be caused by dysphagia, a swallowing disorder that can lead to aspiration, pneumonia and infection. A speech-language pathologist can assess and treat dysphagia and help the client improve their swallowing function.

Choice B is wrong because fine motor tremors are not related to speech or language problems.

They may be caused by damage to the cerebellum or basal ganglia, parts of the brain that control movement and coordination.

Choice C is wrong because facial flushing is not related to speech or language problems.

It may be caused by high blood pressure, fever, anxiety or other conditions.

Choice D is wrong because urinary incontinence is not related to speech or language problems.

It may be caused by damage to the spinal cord, bladder, pelvic floor muscles or nerves that control urination.

A. Place the newborn on their abdomen and observe the movement of their extremities. B. Stroke the newborn’s cheek toward their mouth. C. Stroke upward on the lateral aspect of the newborn’s foot. D. Place the newborn on a flat surface and clap hands loudly.

Correct Answer is D

Explanation

Place the newborn on a flat surface and clap hands loudly.

This action will elicit the Moro reflex, also known as the startle reflex, which is a normal, involuntary reaction that newborns and infants have when they’re startled. In response to the sound, the baby will throw back his or her head, extend out his or her arms and legs, cry, then pull the arms and legs back in.

Choice A is wrong because placing the newborn on their abdomen and observing the movement of their extremities will not trigger the Moro reflex.

This position may elicit other reflexes such as the crawling reflex or the tonic neck reflex.

Choice B is wrong because stroking the newborn’s cheek toward their mouth will not trigger the Moro reflex. This action will elicit the rooting reflex, which helps the baby find the breast or bottle to start feeding.

Choice C is wrong because stroking upward on the lateral aspect of the newborn’s foot will not trigger the Moro reflex. This action will elicit the Babinski reflex, which causes the big toe to extend upward and the other toes to fan out.

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A nurse is reviewing a client’s laboratory results prior to administering the client’s medications. The nurse notes that the client’s lithium level is 2.0 mEq/L. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is recovering from a recent stroke. Which of the following findings should indicate to the nurse the need for a referral to a speech-language pathologist?

Correct Answer is A

Explanation

A nurse is checking a newborn’s Moro reflex. Which of the following actions should the nurse take to elicit this reflex?

Correct Answer is D

Explanation

A nurse is caring for a client at a follow-up visit who has been taking lithium therapy for bipolar disorder. Which of the following findings should indicate to the nurse that the client is experiencing lithium toxicity?

A nurse is reinforcing teaching with a newly licensed nurse about discharge planning. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

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A nurse is reinforcing teaching with a newly licensed nurse about delegating tasks to assistive personnel (AP). Which of the following task-specific information should the nurse identify as a contraindication to delegating a task to an AP?

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A nurse is preparing a room for a client who has a tracheostomy tube. Which of following supplies should the nurse place in the room?

A nurse is caring for a client who has heart failure and is taking furosemide. Which of the following statements by the client indicates a need for the nurse to intervene?

A nurse is reviewing a client’s laboratory results prior to administering the client’s medications. The nurse notes that the client’s lithium level is 2.0 mEq/L.
Which of the following findings should the nurse expect?