The nurse should monitor the temperature of the environment of a client who becomes easily agitated, with awareness that increased temperatures sometimes may cause the client to become:
Calm
Depressed
Agitated
Confused
The Correct Answer is C
Choice A rationale: High temperatures do not usually cause people to become calm unless they are suffering from heat exhaustion or heat stroke, which are medical emergencies.
Choice B rationale: depression is usually associated with low temperatures and reduced sunlight exposure rather than high temperatures.
Choice C rationale: high temperatures is associated with arousal and agitation in some individuals which may be due to the effects of heat on the individual’s nervous system, cardiovascular, and endocrine systems.
Choice D rationale: confusion is not usually associated with confusion. However, it may result in confusion in older adults and individuals with other underlying conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Clozapine has no effect on a patient’s blood pressure levels. However, blood pressure monitoring for all patients is crucial but the temperature is more relevant for a patient on clozapine.
Choice B rationale: Clozapine has no effect on an individual’s respiratory rate hence in this case it is not the priority vital sign to monitor.
Choice C rationale: Clozapine use does not cause pain. Furthermore, pain is not a vital sign.
Choice D rationale: One of the side effects of clozapine is agranulocytosis hence this predisposes the patient to infections which may manifest with fever. Therefore, it is important to monitor the patient’s temperature while on treatment.
Correct Answer is C
Explanation
Choice A rationale: Both sodium and chloride are important for fluid balance but chloride has no effect on the blood lithium levels.
Choice B rationale: sodium has an effect on the blood lithium levels by competing with lithium for reabsorption in the kidneys but vitamins do not influence the lithium levels in blood.
Choice C rationale: dehydration increases the risk of lithium toxicity since it will result in oliguria hence increasing the risk of lithium toxicity since the drug is primarily excreted in urine. Sodium and lithium compete for reabsorption in the kidneys, so low sodium levels can increase lithium retention and lead to toxicity. Therefore, the client should maintain an adequate intake of sodium and water to prevent dehydration and sodium loss and to keep the lithium level within the therapeutic range.
Choice D rationale: water has an influence on blood lithium levels since adequate intake minimizes the risk of toxicity by increasing the drug’s excretion in urine.
However, potassium does not compete with lithium for reabsorption.
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