A nurse on an inpatient mental health unit is admitting a client.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Buprenorphine is not typically indicated for alcohol withdrawal; it is primarily used in the management of opioid dependence.
B. Bupropion is an antidepressant medication and is not indicated for the treatment of acute alcohol withdrawal.
C. Disulfiram is used as a deterrent to alcohol consumption in individuals who have achieved abstinence and is not indicated for acute alcohol withdrawal.
D. Chlordiazepoxide is a benzodiazepine medication commonly used to manage alcohol withdrawal symptoms, such as anxiety and agitation.
Correct Answer is C
Explanation
A. Changing the subject when the client becomes upset may invalidate their feelings and hinder emotional expression and processing.
B. Discouraging the client from forming new relationships may deprive the client of potentially meaningful connections during their remaining time.
C. Allowing the client unlimited time for the grieving process acknowledges the client's emotional response to their diagnosis and respects their individual needs and coping mechanisms.
D. Offering advice about treatment choices may be appropriate in some situations but should be done in collaboration with the client's healthcare team and in consideration of their wishes and values.
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