A nurse is admitting a client to the mental health unit.

Exhibits

The nurse is developing a plan of care for the client. Which of the following interventions should the nurse include? (Select all that apply.)

Notify the provider of potential medication interactions.

Discuss contraception with the client.

Set up a dietary consult for a low-sodium diet.

Educate the client about the need for hemodialysis.

Administer prochlorperazine.

Withhold next dose of lithium.

Answer and Explanation

Correct Answer : A,E,F

A. Notify the provider of potential medication interactions: Furosemide, a loop diuretic, and NSAIDs like ibuprofen can increase lithium levels, contributing to toxicity. Notifying the provider is essential to reassess the medication regimen, especially with current signs of toxicity.
B. Discuss contraception with the client: There is no indication in the scenario that contraception counseling is an immediate priority or concern for this client at this time.
C. Set up a dietary consult for a low-sodium diet: Low-sodium diets can increase lithium reabsorption, worsening lithium toxicity. In fact, the client has hyponatremia (Na+ 131) already, so a low-sodium diet is contraindicated.
D. Educate the client about the need for hemodialysis: While hemodialysis may be required in severe lithium toxicity, this decision should be made by the provider. The nurse should monitor and report symptoms but not initiate education about dialysis unless prescribed.
E. Administer prochlorperazine: This is appropriate PRN medication for nausea and vomiting, which are symptoms of lithium toxicity and are present in this client.
F. Withhold next dose of lithium: The client’s current lithium level (2.2 mEq/L) is above the toxic range (>2.0 mEq/L). Continuing lithium could worsen toxicity, so the nurse should withhold the next dose and notify the provider.

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Correct Answer is D

Explanation

A. Creatinine decreasing is incorrect. In chronic kidney disease (CKD), serum creatinine levels increase as kidney function declines and the kidneys are less able to excrete waste products.
B. Glomerular filtration rate (GFR) increasing is incorrect. As CKD progresses, GFR decreases, reflecting reduced kidney filtering capacity. An increasing GFR would indicate improving kidney function, which is not typical in progressive CKD.
C. Proteinuria decreasing is incorrect. In CKD, proteinuria (protein in the urine) usually increases due to damage to the glomeruli, allowing proteins like albumin to pass through the filtration barrier into the urine.
D. Urine albumin increasing is correct. As kidney function worsens, the glomeruli become more permeable, leading to increased albumin in the urine, known as albuminuria or proteinuria. This is a key marker of kidney damage and progression of CKD.

A. Offer sympathy and attention to maladaptive behavior. B. Maintain same staff members caring for the client. C. Encourage the client to talk about feelings prior to maladaptive behavior. D. Initiate suicide precautions. E. Explore feelings of abandonment with the client. F. Instruct the client to avoid foods with tyramine. G. Apply wrist restraints. H. Offer the client opportunities for physical exercise.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"C"},"H":{"answers":"A"}}

Explanation

Anticipated Actions:

Maintain same staff members: Provides consistency and builds trust—essential in managing clients with emotional instability.

Encourage talking about feelings prior to self-harm: Helps identify emotional triggers and promotes healthy coping strategies.

Initiate suicide precautions: Critical given self-harm, feelings of hopelessness, and verbalizations of loneliness.

Explore feelings of abandonment: Therapeutic to address the underlying emotional distress linked to relationship loss.

Offer opportunities for physical exercise: Can reduce tension and improve mood in a structured, healthy way.

Contraindicated Actions:

Offer sympathy and attention to maladaptive behavior: Reinforces self-harm as a means to gain attention, which can perpetuate the behavior.

Apply wrist restraints: Physical restraints are only appropriate when a client poses an immediate risk to self or others and all less restrictive options have failed. In this scenario, suicide precautions and monitoring are more appropriate first-line interventions.

Non-essential Action:

Instruct the client to avoid foods with tyramine: Relevant only if the client is taking MAOIs (e.g., phenelzine), which isn’t indicated in the scenario.

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A nurse is admitting a client to the mental health unit. Exhibits The nurse is developing a plan of care for the client. Which of the following interventions should the nurse include? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has progressing chronic kidney disease (CKD). Which of the following laboratory results would the nurse expect to find in the client's electronic health record?

Correct Answer is D

Explanation

A nurse in a mental health facility is caring for a client. Exhibits For each potential nursing action, click to specify if the potential action is anticipated, nonessential, or contraindicated for the client.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"C"},"H":{"answers":"A"}}

Explanation

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A nurse is admitting a client to the mental health unit.

Exhibits

The nurse is developing a plan of care for the client. Which of the following interventions should the nurse include? (Select all that apply.)