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A nurse on a mental health unit is caring for a client.

Nurses' Notes

Day 1, 1300:

Client admitted following a suicide attempt. Client's family reports client has not left bedroom in 1 week. Client previously. diagnosed with bipolar disorder.

Client reports feeling excessively tired and light-headed. Allergies: Client's family reports allergy to SSRIS (angioedema) and penicillin (anaphylaxis).

1600:

Client has been sleeping in their room since admission. Flat affect noted.

For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

A.

Low-sodium diet

B.

Potassium 40 mEq PO daily

C.

Initiate suicide precautions

D.

Fluoxetine 20 mg PO daily

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

A. Low-sodium diet Contraindicated: A low-sodium diet can decrease lithium elimination, leading to increased lithium levels and risk of toxicity in lithium users. B. Potassium 40 mEq PO daily Anticipated: Potassium supplementation may be needed to prevent hypokalemia, which can occur due to lithium-induced polyuria or diuretic use. C. Initiate suicide precautions Anticipated: Suicide precautions are essential for any client who has attempted or expressed suicidal ideation, especially during the depressive phase of bipolar disorder. D. Fluoxetine 20 mg PO daily Contraindicated: Fluoxetine is an SSRI antidepressant, which can cause angioedema in clients who are allergic to SSRIs. Additionally, fluoxetine can trigger manic episodes or increase suicidal risk in clients with bipolar disorder.


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Related Questions

Correct Answer is D

Explanation

A. Incorrect. Aspirin can trigger asthma attacks in some children and should be avoided.

B. Incorrect. The peak expiratory flow meter should be used daily, not just when the child has symptoms, and the highest reading should be recorded, not the average.

C. Incorrect. Carpet can harbor dust mites, mold, and other allergens that can worsen asthma. It is better to have hardwood or tile floors and washable rugs.

D. Correct. Influenza immunization can prevent serious complications from respiratory infections in children with asthma.

Correct Answer is B

Explanation

  • Urinary output is an important indicator of fluid balance and kidney function. After delivery, a woman may experience increased urinary output due to the loss of excess fluid that was retained during pregnancy and the diuretic effect of oxytocin, which is released during breastfeeding. This is a normal and expected finding in the postpartum period.
  • However, increased urinary output may also be a sign of urinary retention, which is the inability to empty the bladder completely. Urinary retention can occur due to trauma to the bladder or urethra during delivery, swelling or hematoma of the perineum, epidural anesthesia, or decreased bladder sensation.Urinary retention can lead to complications such as infection, bladder distension, or postpartum hemorrhage.
  • Therefore, when a woman who delivered a normal newborn 24 hours ago reports that she seems to be urinating every hour or so, the practical nurse (PN) should measure the next voiding, then palpate the client's bladder. This will help to assess the amount and quality of urine and the presence or absence of bladder distension. A normal urine output is about 30 ml per hour, and a normal bladder should feel soft and empty after voiding. If the urine output is low or high, or if the bladder feels firm or full after voiding, the PN should report these findings to the primary healthcare provider for further evaluation and intervention.

Therefore, option B is the correct answer, while options A, C, and D are incorrect.

Option A is incorrect because catheterizing the client for residual urine volume is an invasive procedure that should only be done if indicated by the primary healthcare provider.

Option C is incorrect because evaluating for normal involution and massaging the fundus are related to uterine function, not urinary function.

Option D is incorrect because obtaining a specimen for urine culture and sensitivity is not necessary unless there are signs of infection, such as fever, dysuria, or foul-smelling urine.

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