A nurse on an inpatient mental health unit is admitting a client.

Exhibits

The nurse is reviewing the client's medical record at 0830 on day 2 of admission.

For each finding, click to specify whether the finding indicates a potential improvement in or a potential worsening of the client's condition.

Blood pressure

Gait when ambulating

Lithium level

Urine amount and color

Blurred vision

Answer and Explanation

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

Blood pressure Potential worsening: The blood pressure dropped from 114/64 mm Hg on Day 1 to 98/56 mm Hg on Day 2, indicating a potential worsening as it decreased.

Gait when ambulating - Potential worsening: The client's gait was noted to be uncoordinated when ambulating to the bathroom on Day 2, suggesting a potential worsening in motor coordination or balance.

Lithium level Potential worsening: The lithium level increased from 1.9 mEq/L on Day 2, exceeding the therapeutic range (less than 1.5 mEq/L), indicating a potential worsening due to lithium toxicity.

Urine amount and color - Potential worsening: polyuria is a sign of lithium toxicity.

Blurred vision Potential worsening: The client reports blurred vision and frequently rubs their eyes on Day 2, indicating a potential worsening of visual acuity or ocular health.

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Correct Answer is ["A","B","D","F","I"]

Explanation

A. The blood alcohol level of 510 mg/dL indicates severe intoxication and requires monitoring for potential complications, such as respiratory depression or alcohol withdrawal.

B. The client's recent loss of both parents is significant and may contribute to the relapse of alcohol use disorder. It warrants further assessment of the client's coping mechanisms and emotional state.
C. Smoking history:

While the client's smoking history may be relevant to their overall health, it is not a priority for follow-up in this scenario where the client's alcohol intoxication and potential withdrawal symptoms are the primary concerns.
D. The client's recent consumption of alcohol, as reported by the family member, is crucial information for assessing the risk of alcohol withdrawal and planning appropriate
interventions.

E. Cardiac assessment:
The client's vital signs indicate normal sinus rhythm and stable blood pressure, suggesting no acute cardiac issues at present. Given the focus on alcohol intoxication and potential withdrawal, a comprehensive cardiac assessment is not immediately warranted.
F. The neurological assessment is essential to monitor for signs of alcohol withdrawal, such as tremors, hallucinations, or seizures, given the client's history of alcohol use disorder and current intoxication.
G. Genitourinary assessment:

While assessing the genitourinary system is important in a comprehensive nursing assessment, there are no indications in the provided information to suggest acute genitourinary issues requiring immediate follow-up. The client's current symptoms and history primarily suggest alcohol intoxication and potential withdrawal.
H. Respiratory assessment:

The client's respiratory assessment indicates clear lung sounds and adequate oxygen saturation, suggesting no acute respiratory distress at the time of admission. While
respiratory status should be monitored, it is not a priority for immediate follow-up compared to the client's alcohol intoxication and potential withdrawal.
I. Assessing the gastrointestinal system is important to evaluate the client's nutritional status, assess for signs of liver disease or other gastrointestinal complications associated with alcohol use disorder, especially considering the reported weight loss and minimal appetite.

A. Administer methadone hydrochloride. B. Monitor for orthostatic hypotension. C. Acidify the client's urine. D. Implement seizure precautions.

Correct Answer is D

Explanation

A. Methadone hydrochloride is not indicated for the management of alcohol intoxication or withdrawal. It is primarily used for opioid addiction treatment.
B. While monitoring for orthostatic hypotension is important in clients with alcohol use disorder, implementing seizure precautions is a higher priority because alcohol withdrawal can lead to
seizures.
C. Acidifying the client's urine is not indicated in the care of an intoxicated client with alcohol use disorder.
D. Implementing seizure precautions is essential in clients with alcohol use disorder who are at risk for alcohol withdrawal syndrome, which can include seizures as a potential complication.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health facility is admitting a client. Exhibits A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.

Correct Answer is ["A","B","D","F","I"]

Explanation

A nurse in an acute care facility is planning care for a client who has a history of alcohol use disorder and is admitted while intoxicated. Which of the following interventions should the nurse plan for the client?

Correct Answer is D

Explanation

A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?

A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?

A nurse observes the caregiver of a client who has Alzheimer's disease throwing magazines on the floor and crying. Which of the following actions should the case manager take first?

A nurse is preparing for an interprofessional meeting to discuss the plan of care for a client. Which of the following information should the nurse plan to communicate to a social worker?

A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?

A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take?

A nurse is caring for a client who has right-sided hemiplegia following a recent stroke. Which of the following questions should the nurse ask to determine the client's ability to cope?