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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Correct Answer is D

Explanation

Choice A: Administering a half dose now is not advisable, because it may result in underdosing or overdosing of digoxin. Digoxin has a narrow therapeutic range and a high risk of toxicity, especially in infants and children. The amount of digoxin absorbed by the infant before vomiting is unknown, so giving a partial dose may not achieve therapeutic levels or may exceed safe levels.

Choice B: Giving another dose is not advisable, because it may result in overdosing of digoxin. Digoxin has a narrow therapeutic range and a high risk of toxicity, especially in infants and children. The amount of digoxin absorbed by the infant before vomiting is unknown, so giving a full dose may exceed safe levels and cause adverse effects such as nausea, vomiting, bradycardia, arrhythmias, or visual disturbances.

Choice C: Mixing the next dose with food is not advisable, because it may affect the absorption and bioavailability of digoxin. Digoxin should be taken on an empty stomach or at least one hour before or two hours after meals, because food can interfere with its absorption from the gastrointestinal tract and reduce its effectiveness.

Choice D:Withholding the dose is the safest option. If vomiting occurs within 30 minutes of administration, it’s generally advised to skip that dose to avoid the risk of overdose.The next dose should be given as scheduled Digoxin has a long half-life and accumulates in tissues, so missing one dose will not significantly affect its therapeutic effect. Withholding this dose will avoid overdosing and toxicity of digoxin, which can be life-threatening in infants and children. The nurse should also advise the mother to resume the regular dosing schedule and monitor the infant's pulse rate and signs of digoxin toxicity.

A. Continue to monitor the client for signs of an infection. B. Call the healthcare provider for a prescription for linezolid. C. Collect multiple sets of blood cultures for MRSA screening. D. Place the client on contact transmission precautions.

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

Explanation

Choice A reason: This is a correct answer because continuing to monitor the client for signs of an infection is important to detect any recurrence or complication of MRSA infection. MRSA is a type of bacteria that is resistant to many antibiotics and can cause serious skin, soft tissue, bone, joint, or bloodstream infections. The nurse should assess the client's vital signs, wound appearance, pain level, and laboratory results.

Choice B reason: This is not a correct answer because calling the healthcare provider for a prescription for linezolid is not necessary unless the client has an active MRSA infection that requires treatment. Linezolid is an antibiotic that can be used to treat MRSA infections, but it has potential side effects and interactions that need to be considered. The nurse should not prescribe or administer antibiotics without a valid order.

Choice C reason: This is a correct answer because collecting multiple sets of blood cultures for MRSA screening is important to identify any asymptomatic bacteremia or sepsis that could result from MRSA infection. MRSA can enter the bloodstream through wounds, catheters, or surgical sites and cause life-threatening complications such as endocarditis, osteomyelitis, or pneumonia. The nurse should obtain blood samples from different sites and times and send them to the laboratory for analysis.

Choice D reason: This is a correct answer because placing the client on contact transmission precautions is important to prevent the spread of MRSA to other clients, staff, or visitors. Contact transmission precautions include wearing gloves and gowns when entering the client's room, using dedicated or disposable equipment, and performing hand hygiene before and after contact with the client or their environment.

Choice E reason: This is not a correct answer because obtaining a sputum specimen for culture and sensitivity is not relevant to the client's history of MRSA wound infection. Sputum culture and sensitivity is a test that can be used to diagnose respiratory infections caused by bacteria, fungi, or viruses. The nurse should only obtain a sputum specimen if the client has signs or symptoms of a respiratory infection, such as cough, fever, chest pain, or dyspnea.

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Naxlex Comprehensive Predictor Exams

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

Correct Answer is D

Explanation

A male client is admitted for the removal of an internal fixation device that was inserted for a fractured ankle. During the client's admission history, he tells the nurse that he recently received vancomycin for a methicillin-resistant Staphylococcus aureus (MRS

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

Explanation

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