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A nurse is caring for a client.

Exhibits

The nurse is collecting data from the client 12 hr later.

How should the nurse interpret the following findings?

For each potential finding, click to specify whether the finding is an indication of potential improvement or an indication of potential worsening condition.

A.

Vision

B.

Lithium level

C.

Urine output

D.

Mucous membranes

E.

Vital signs

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

  • Vision (Blurred)

    • Interpretation: Potential worsening condition
    • Rationale: Blurred vision can be a sign of lithium toxicity. Despite the lithium level improving, this symptom indicates that neurotoxicity may still be present.

  • Lithium Level (1.2 mEq/L)

    • Interpretation: Potential improvement
    • Rationale: The lithium level has decreased from 1.8 mEq/L (toxic) to 1.2 mEq/L, which is within the therapeutic range (0.6-1.2 mEq/L). This indicates that treatment to lower lithium toxicity is effective.

  • Urine Output (40 mL/hr)

    • Interpretation: Potential improvement
    • Rationale: A urine output of 40 mL/hr is within the acceptable range (normal is greater than 30 mL/hr), suggesting that kidney function is adequate and not compromised by lithium toxicity.

  • Mucous Membranes (Pale, Dry)

    • Interpretation: Potential worsening condition
    • Rationale: Pale, dry mucous membranes suggest dehydration, which can increase the risk of lithium toxicity and negatively affect overall health.

  • Vital Signs (BP 88/50 mm Hg, Pulse 96/min)

    • Interpretation: Potential worsening condition
    • Rationale: The drop in blood pressure from 130/84 mm Hg to 88/50 mm Hg indicates hypotension. This could be related to dehydration or lithium toxicity, and it requires follow-up as the condition is deteriorating.


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Related Questions

Correct Answer is A

Explanation

Choice A rationale:
HIV is primarily transmitted through direct contact with infected body fluids, such as blood, semen, vaginal fluids, and breast milk. This can occur during unprotected sex, sharing of needles, or from mother to child during childbirth or breastfeeding.
Choice B rationale:
Mosquitoes do not transmit HIV. The virus does not replicate or survive well within insects.
Choice C rationale:
Casual contact, such as hugging, shaking hands, or sharing dishes, does not lead to HIV transmission.
Choice D rationale:
Accidental puncture wounds can potentially transmit HIV, but this is not the primary mode of transmission. It’s more common in healthcare settings where workers might be exposed to needlestick injuries.

Correct Answer is A

Explanation

Choice A rationale:
Diabetes insipidus is characterized by excessive thirst and excretion of large amounts of severely dilute urine, leading to dehydration.
Choice B rationale:
Bradycardia is not a typical finding in diabetes insipidus.
Choice C rationale:
Polyphagia (excessive hunger) is more commonly associated with diabetes mellitus, not diabetes insipidus.
Choice D rationale:
Hyperglycemia is a symptom of diabetes mellitus, not diabetes insipidus.

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