A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lbs) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

identify the client's nutritional status.

Provide a structured environment for the client.

Plan a therapeutic diet for the client

Request à mental health consult.

Answer and Explanation

The Correct Answer is A

A. Identify the client's nutritional status.

Explanation:

Given the significant weight loss and the client's distorted belief about her body image (believing she is fat despite losing weight), it is crucial to assess the client's nutritional status first. Rapid weight loss and distorted body image are characteristic features of an eating disorder, such as anorexia nervosa. The nurse needs to determine the extent of malnutrition and potential medical complications related to inadequate nutrition. This assessment will guide the subsequent interventions.

Why the other choices are incorrect:

B. Provide a structured environment for the client.

While providing a structured environment can be important in managing eating disorders, such as anorexia nervosa, it is not the first priority. Understanding the client's nutritional status and medical condition takes precedence.

C. Plan a therapeutic diet for the client.

Planning a therapeutic diet may be part of the client's care plan, but without understanding the underlying nutritional status and potential eating disorder, creating a diet plan may not be effective or appropriate.

D. Request a mental health consult.

While a mental health consult is important for addressing the client's distorted body image and potential eating disorder, it should follow the assessment of nutritional status. The nutritional assessment provides critical information for both medical and psychological interventions.

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Correct Answer is A

Explanation

Lithium is a commonly used medication for treating bipolar disorder, and therapeutic drug monitoring is crucial to ensure its effectiveness and prevent potential toxicity. Monitoring the client's lithium levels in the blood is important because lithium has a narrow therapeutic range, meaning that levels that are too low might not provide the desired therapeutic effect, while levels that are too high can lead to toxicity.

B) "This medication is addictive, so you will need to discontinue it in six months."

Lithium is not considered addictive. It's important to provide accurate information about the nature of the medication to avoid unnecessary concerns.

C) "Weight gain should be reported to your provider as an indication of lithium toxicity."

While weight gain can be a side effect of some medications, it's not a specific indicator of lithium toxicity. Lithium toxicity is characterized by a range of symptoms including tremors, confusion, nausea, vomiting, and excessive thirst, among others.

D) "Your provider may prescribe a diuretic if you have trouble urinating while taking lithium."

Diuretics are generally not recommended with lithium because they can increase the risk of lithium toxicity. Lithium can affect kidney function, and using diuretics may exacerbate this effect. The client should be advised not to use diuretics without consulting their healthcare provider.

Correct Answer is ["0.75"]

Explanation

To calculate the volume (ml) of haloperidol decanoate needed for a dose of 75 mg, you can use the following formula:

Volume (ml) = Dose (mg) / Concentration (mg/ml)

Given:

Dose = 75 mg

Concentration = 100 mg/ml

Plugging in the values:

Volume (ml) = 75 mg / 100 mg/ml

Volume (ml) = 0.75 ml

Rounding to the nearest hundredth:

Volume (ml) = 0.75 ml

So, the nurse should administer 0.75 ml of haloperidol decanoate for the dose of 75 mg.

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A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lbs) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has bipolar disorder about lithium. Which of the following statements should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is preparing to administer haloperidol 75 mg IM per week. Available is haloperidol decanoate 100mg/ml for injection. How many ml should the nurse administer per dose? (Round the answer to the nearest hundredth. Use a leading zero if it applies.

Correct Answer is ["0.75"]

Explanation

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