A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the nurse that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the nurse to provide?

Unless your sister has a medical education, ignore her comments.

I can hear that your sister's comments are overwhelming you.

Do you think it is possible that you might be a hypochondriac?

Besides your sister's comments, what in your life is troubling you?

Answer and Explanation

The Correct Answer is D

Choice A rationale: Ignoring comments about the sister's lack of medical education may not address the client's feelings and concerns. It is essential to explore the client's emotions.

Choice B rationale: Acknowledging that the sister's comments are overwhelming is supportive but may not actively address the client's self-perception.

Choice C rationale: Asking if the client thinks she might be a hypochondriac could be interpreted as judgmental and may not promote an open discussion about the client's concerns.

Choice D rationale: Asking about what is troubling the client, besides her sister's comments, encourages the client to express her feelings and provides an opportunity for the nurse to understand the client's perspective and concerns.

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Correct Answer is D

Explanation

Choice A rationale: Alkaline phosphatase is not typically associated with the monitoring of lithium therapy. The primary concern is renal function.

Choice B rationale: Blood glucose is not the most critical parameter to monitor before initiating lithium therapy. The focus is on renal function.

Choice C rationale: White blood count is not the primary laboratory value to assess before starting lithium. Renal function is more critical.

Choice D rationale: Serum creatinine is the most important laboratory finding to review before beginning lithium therapy. Lithium is primarily excreted by the kidneys, and impaired renal function can lead to lithium toxicity. Regular monitoring of renal function, including serum creatinine levels, is crucial to prevent adverse effects.

A. Disrupts group activities. B. Refuses antipsychotic medications. C. Wanders into client's rooms. D. Talks with nonsensical words.

Correct Answer is C

Explanation

Choice A rationale: Disrupting group activities is a concerning behavior but may not necessitate constant observation. The key is to assess the potential for harm to self or others.

Choice B rationale: Refusing antipsychotic medications is a significant concern, but it alone may not warrant constant observation. The nurse needs to assess the client's overall behavior and the potential for harm.

Choice C rationale: Wandering into clients' rooms poses a risk to the safety of both the client and others. This behavior indicates a need for constant observation to prevent harm or inappropriate interactions.

Choice D rationale: Talking with nonsensical words is a symptom of the client's mental health condition but may not be the sole criterion for constant observation. The nurse should assess the overall risk to safety.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes lithium carbonate for a client diagnosed with bipolar, manic depression. It is most important for the nurse to review which laboratory finding prior to beginning the drug therapy?

Correct Answer is D

Explanation

A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client's rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?

Correct Answer is C

Explanation

A 16-year-old female client is admitted to the psychiatric unit and states that she is depressed and anxious. The client appears frail and is wearing baggy clothes. When it is time for lunch, the client states, "I can't eat, I'm already overweight." What is the best response by the nurse?

A client with chronic alcohol dependence is diagnosed with Wernicke-Korsakoff syndrome. The client is experiencing memory loss and confusion. Which medication should the nurse administer to help alleviate the client's symptoms?

Which client Information indicates the need for the nurse to use the CAGE questionnaire during the admission interview?

The nurse is assessing a client with postpartum depression for changes in the mood and cognitive state. Which subjective finding(s) should the nurse identify that are consistent with postpartum depression? Select all that apply.

An 18-year-old client is brought to the emergency department with a suspected drug overdose. Which information is most important for the nurse to obtain from the family?

The nurse is providing teaching to a client and family about schizophrenia before discharge from an inpatient facility. The nurse should instruct the family to notify the healthcare provider when which behavior is observed?