A nurse is caring for a client who has bipolar disorder

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

After assessing the client and reviewing the client's medical record, the nurse determines that the client could be experiencing which of the following?

The client could be experiencing
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and
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.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Rationale for Correct Answers:

Lithium toxicity: The client’s lithium level is 1.8 mEq/L, which exceeds the therapeutic range of 0.8 to 1.2 mEq/L. Combined with symptoms like diarrhea, vomiting, coarse tremors, confusion, and ataxia, this strongly suggests lithium toxicity, a medical emergency that requires immediate intervention.
Hypothyroidism: The thyroid profile shows low T3 (71 ng/dL) and free T4 (0.6 ng/dL), along with low-normal TSH (0.3 mu/mL). These values are consistent with hypothyroidism, which can be a side effect of long-term lithium use. Symptoms such as lethargy and disorientation may also reflect thyroid dysfunction.

Rationale for Incorrect Choices:

Hyperglycemia: The glucose level is 100 mg/dL, which is within the normal reference range. The client has no symptoms of hyperglycemia such as polyuria, polydipsia, or blurred vision.
Acute kidney injury: The client’s BUN (18 mg/dL) and creatinine (0.9 mg/dL) are within normal limits, indicating that kidney function is preserved at this time and does not meet the criteria for acute kidney injury.

Nursing Test Bank

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Free Nursing Study Resources

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

Explanation

A. Increased heart rate: Tachycardia occurs as a compensatory mechanism in fluid overload due to the heart working harder to circulate the excess volume. The increased preload stretches the myocardial fibers, triggering a higher heart rate to maintain effective perfusion.

B. Increased blood pressure: Excess fluid volume raises intravascular pressure, leading to hypertension. The increased circulating volume causes elevated preload and afterload, resulting in increased cardiac output and higher blood pressure readings.

C. Increased respiratory rate: Fluid overload can lead to pulmonary congestion or edema, impairing gas exchange. The body compensates by increasing the respiratory rate to improve oxygenation and reduce carbon dioxide levels, especially if dyspnea is present.

D. Increased hematocrit: Hematocrit levels typically decrease in fluid overload due to hemodilution. The plasma volume expands relative to red blood cell concentration, leading to a dilutional effect that lowers hematocrit levels.

E. Increased temperature: Fever is not a typical finding in fluid overload and is more indicative of infection or inflammation. In fluid overload, temperature generally remains within normal limits unless an underlying infectious process is also present.

A. Information about a client can be disclosed to family members at any time." B. "HIPAA established regulations of individually identifiable health information in verbal, electronic or written form.” C. “A client's address would be an example of personally identifiable information.” D. “HIPAA is a federal law, not a state law.”

Correct Answer is A

Explanation

A. Information about a client can be disclosed to family members at any time: HIPAA restricts disclosure of health information without the client’s consent or unless the disclosure meets specific legal criteria. Information can only be shared with family members if the client provides authorization or if it is deemed necessary for care and the client does not object.

B. HIPAA established regulations of individually identifiable health information in verbal, electronic or written form: HIPAA’s purpose includes protecting all forms of individually identifiable health information—spoken, written, or electronic. HIPAA ensures confidentiality and sets national standards for data security and patient privacy.

C. A client's address would be an example of personally identifiable information: Under HIPAA, a client’s address is considered part of their protected health information (PHI) because it can be used to identify the individual. Such data must be safeguarded to prevent unauthorized disclosure or access.

D. HIPAA is a federal law, not a state law: HIPAA is a federal law passed in 1996, and it sets nationwide standards for protecting health information. While states may enact stricter privacy laws, HIPAA forms the foundational legal framework for patient confidentiality across the U.S.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

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

Explanation

A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

Correct Answer is A

Explanation

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