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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C is correct because vitamin K can interfere with the anticoagulant effect of warfarin and increase the risk of clotting. The client should maintain a consistent intake of vitamin K from food sources, such as dark green leafy vegetables, to avoid fluctuations in the blood levels of warfarin.
Choice A is incorrect because increasing the intake of dark green leafy vegetables while taking warfarin can decrease the effectiveness of warfarin and increase the risk of clotting.
Choice B is incorrect because eating two servings of dark green leafy vegetables daily and continuing for 30 days after warfarin therapy is completed can cause unpredictable changes in the blood levels of warfarin and increase the risk of bleeding or clotting.
Choice D is incorrect because avoiding any foods that contain any vitamin K while taking warfarin can increase the sensitivity to warfarin and increase the risk of bleeding.
Correct Answer is C
Explanation
Choice A: Yellow-tinged sputum is not a critical finding for the nurse to report, as this is a common sign of pneumonia and does not indicate an adverse reaction to meropenem. This is a distractor choice.
Choice B: Nausea and headache are not urgent findings for the nurse to report, as these are mild side effects of meropenem and can be managed with supportive measures. This is another distractor choice.
Choice C: Watery diarrhea is an important finding for the nurse to report, as this can indicate a serious complication of meropenem, such as Clostridioides difficile infection, which can cause severe dehydration, electrolyte imbalance, and sepsis. Therefore, this is the correct choice.
Choice D: Increased fatigue is not a significant finding for the nurse to report, as this can be related to the client's underlying condition and does not suggest a problem with meropenem. This is another distractor choice.
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