An adult client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the health care provider?

Reference Range
Blood alcohol level [Reference Range: 0 to 10.9 mmol/L (0% to 0.05%)]
Lithium [Reference Range: 0.8 to 1.2 mEq/L or 0.8 to 1.2 mmol/L]

Blood alcohol level of 0.09% (90 mmol/L)

Six hours of sleep in the past three days.

Serum lithium level of 1.6 mEq/L (1.6 mmol/L)

Weight loss of 10 pounds (4.5 kg) in past month.

Answer and Explanation

The Correct Answer is C

Choice A: Blood alcohol level of 0.09% (90 mmol/L) is not the most important finding for the nurse to report, as this is within the reference range and does not indicate alcohol intoxication or withdrawal, which can affect the client's mental status and mood stability. This is a distractor choice.

Choice B: Six hours of sleep in the past three days is not the most important finding for the nurse to report, as this is a common symptom of bipolar disorder during manic episodes and does not require immediate intervention by the health care provider. This is another distractor choice.

Choice C: Serum lithium level of 1.6 mEq/L (1.6 mmol/L) is the most important finding for the nurse to report, as this indicates lithium toxicity, which can cause neurological and renal impairment and potentially fatal complications such as seizures, coma, and cardiac dysrhythmias. Therefore, this is the correct choice.

Choice D: Weight loss of 10 pounds (4.5 kg) in past month is not the most important finding for the nurse to report, as this may be related to decreased appetite or increased activity during manic episodes and does not pose an immediate threat to the client's health or safety. This is another distractor choice.

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Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

Choice A: Taking metformin with the morning and evening meal is a correct statement for the nurse to include, as this can improve the absorption and effectiveness of metformin and reduce the risk of gastrointestinal side effects. Therefore, this is a correct choice.

Choice B: Using sliding scale insulin for frequent blood glucose elevations is not a correct statement for the nurse to include, as this is not recommended for clients with type 2 DM who are taking metformin. This can cause hypoglycemia and complicate the management of blood glucose levels. This is an incorrect choice.

Choice C: Recognizing signs and symptoms of hypoglycemia is a correct statement for the nurse to include, as this can help the client identify and treat low blood glucose levels, which can occur with metformin use or other factors such as exercise, fasting, or alcohol intake. Therefore, this is another correct choice.

Choice D: Reporting persistent polyuria to the health care provider is a correct statement for the nurse to include, as this can indicate poor glycemic control or a complication of DM such as diabetic ketoacidosis or nephropathy. Therefore, this is another correct choice.

Choice E: Taking an additional dose for signs of hyperglycemia is not a correct statement for the nurse to include, as this can cause overdose or toxicity of metformin, which can lead to lactic acidosis and renal failure. This is another incorrect choice.

A. Provide bedside equipment for transmission and protective precautions. B. Evaluate daily serum electrolytes and hydration status. C. Culture sputum, urine, burn wound, and all intravenous access sites. D. Implement central line-associated bloodstream infection (CLABSI) protocols.

Correct Answer is C

Explanation

Choice A: Providing bedside equipment for transmission and protective precautions is not the first action that the nurse should implement, as this is a standard precaution that should be already in place for all clients in the critical care unit. This is a distractor choice.

Choice B: Evaluating daily serum electrolytes and hydration status is not the first action that the nurse should implement, as this is a routine assessment that can be done later after addressing the immediate problem of infection. This is another distractor choice.

Choice C: Culturing sputum, urine, burn wound, and all intravenous access sites is the first action that the nurse should implement, as this can help identify the source and type of infection, which can guide the appropriate antibiotic therapy and prevent further complications. Therefore, this is the correct choice.

Choice D: Implementing central line-associated bloodstream infection (CLABSI) protocols is not the first action that the nurse should implement, as this is a preventive measure that may not be applicable for this client who already has SIRS. This is another distractor choice.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin 500 mg PO twice daily. Which statement(s) should the nurse include in this client’s teaching plan? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

Correct Answer is C

Explanation

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