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. Weighing the client every other day may contribute to increased anxiety and fixation on weight, which is not recommended for clients with binge eating disorder.
B. Remaining with the client for 1 hour after meals may not be feasible or practical and may not directly address the underlying issues associated with binge eating disorder.
C. Offering snacks when the client is hungry may not address the underlying psychological issues driving binge eating behavior and may inadvertently reinforce unhealthy eating patterns.
D. Planning a menu with the client promotes collaboration, empowers the client to make healthier food choices, and fosters a sense of control over their eating habits, which are important aspects of managing binge eating disorder.
Correct Answer is A
Explanation
A. Safety is paramount, and if a client expresses intent to harm someone, it must be taken seriously and reported to local authorities to prevent harm and ensure the safety of the potential victim.
B. Confidentiality is important, but when there is a threat to harm others, the duty to warn and protect overrides confidentiality.
C. While informing risk management may be appropriate in some situations, when there is an imminent threat of harm, immediate action is necessary, which includes reporting to local authorities.
D. Delaying discharge to work on anger management may not be sufficient to ensure the safety of the potential victim. Reporting the threat to local authorities is necessary to prevent harm.
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