The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?

Five-pound (2.3 kg) weight gain.

Nausea and vomiting.

Short-term memory loss.

Depressed affect.

Answer and Explanation

The Correct Answer is B

Choice A rationale:
A five-pound weight gain in a client taking lithium carbonate is significant. however, the timeframe of the weightgain is to be known. Choice B rationale:
Nausea and vomiting are known side effects of lithium that should be reported as they can cause electrolyte imbalance.

Choice C rationale:
Short-term memory loss is a potential side effect of lithium, but it may not require immediate reporting unless it significantly affects the client's daily functioning or is associated with other concerning symptoms.

Choice D rationale:
A depressed affect is a symptom that should be addressed as part of the client's ongoing psychiatric care, but it may not warrant immediate reporting unless it is severe and requires a change in the treatment plan. The priority in this case is the potential lithium toxicity indicated by the weight gain.

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Correct Answer is A

Explanation

Choice A rationale:
Encouraging the mother to write her thoughts and feelings in a journal is a constructive and therapeutic response. It provides an outlet for the mother to express her emotions and can be a helpful tool for coping with the challenges she is facing.

Choice B rationale:
Determining if the mother has other children who do not have developmental disabilities may be relevant to understanding her support system and family dynamics, but it does not directly address her current emotional distress.

Choice C rationale:
Reassuring the mother that her child will achieve some growth and development milestones may not be appropriate in this situation, as the child's disabilities are described as profound, and it is uncertain what milestones the child will reach. Providing false hope may not be helpful and could be misleading.

Choice D rationale:
Asking the mother if she has ever thought about harming herself or her child is an important inquiry related to her emotional state and the potential risk of harm. However, it should follow the initial response of encouraging her to express her thoughts and feelings in a journal.

A. Measure the client's blood pressure in both arms. B. Screen for a family history of diabetes mellitus. C. Arrange for immediate transport to a medical facility. D. Advise the client to restrict fluids and keep feet elevated. E. Discuss the importance of a regular exercise program.

Correct Answer is ["A","B","E"]

Explanation

Choice A rationale:
Measuring blood pressure in both arms can help assess for potential hypertension, which is a common concern in individuals with abdominal obesity and a high waist-hip ratio.

Choice B rationale:
Screening for a family history of diabetes mellitus is important because individuals with abdominal obesity are at increased risk for type 2 diabetes.

Choice C rationale:
Immediate transport to a medical facility is not indicated based solely on the findings of abdominal obesity, high waist-hip ratio, and elevated BMI. These findings may indicate an increased risk for certain health conditions, but they do not necessitate emergency transport.

Choice D rationale:
Restricting fluids and elevating feet is not a standard intervention based solely on the findings described. This action would be more relevant in specific medical situations, such as managing edema.

Choice E rationale:
Discussing the importance of a regular exercise program is appropriate because it can help address obesity and its associated health risks, including diabetes and hypertension.

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The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The mother of an 8-month-old infant with profound mental and physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth and development milestones. How should the nurse respond to this mother?

Correct Answer is A

Explanation

During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2. Which action(s) should the nurse take in response to these findings? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

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