A nurse is caring for a client who has borderline personality disorder (BPD).
Check the 6 assessment findings that require immediate follow-up:.
Financial situation.
Increased use of mood-altering substances.
Sexual behaviors.
Hepatitis Viral Study (HAA) results.
BUN level.
Hgb level.
Sodium level.
Being admitted frequently
Recent loss of a parent
Correct Answer : B,C,D,G,H,I
Choice A rationale:
Financial situation is a concern but it does not require immediate follow-up in a medical context.
Choice B rationale:
Increased use of mood-altering substances is a serious concern. The client has been drinking heavily and asking for their “nerve” pill, which could indicate substance misuse.
Choice C rationale:
The client’s sexual behaviors, specifically having multiple partners and not using condoms, pose a risk for sexually transmitted infections.
Choice D rationale:
The positive Hepatitis Viral Study (HAA) indicates the presence of a viral hepatitis infection, which requires immediate medical attention.
Choice E rationale:
The BUN level is within the normal range (10 to 20 mg/dL), so it does not require immediate follow-up.
Choice F rationale:
The Hgb level is within the normal range (12 to 18 g/dL), so it does not require immediate follow-up.
Choice G rationale:
The sodium level is below the normal range (136 to 145 mEq/L), indicating hyponatremia, which requires immediate medical attention.
Choice H rationale:
The frequency of facility admissions indicates that the client’s condition is not being managed effectively and requires immediate reassessment.
Choice I rationale:
The recent loss of a parent is a significant life event that could exacerbate the client’s mental health issues and substance misuse, requiring immediate follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Muscle weakness is a manifestation of mild lithium toxicity. Lithium toxicity can occur at therapeutic levels, so clients should be monitored for adverse effects.
Choice B rationale:
Constipation is not typically associated with lithium toxicity. Diarrhea, not constipation, is a symptom of lithium toxicity.
Choice C rationale:
Urinary retention is not a typical symptom of lithium toxicity. Increased urination and thirst are common side effects of lithium.
Choice D rationale:
Hyperactivity is not a typical symptom of lithium toxicity. Lithium is used to manage bipolar disorder and can help reduce hyperactivity.
Correct Answer is C
Explanation
Choice A rationale:
A lithium level of 1.8 mEq/L is above the therapeutic level for initial treatment (0.8 to 1.4 mEq/L)3.
Choice B rationale:
A lithium level of 1.8 mEq/L is above, not below, the therapeutic treatment level.
Choice C rationale:
A lithium level of 1.8 mEq/L is at the toxic level. A blood lithium level greater than 1.5 mEq/L indicates toxicity.
Choice D rationale:
A lithium level of 1.8 mEq/L is not within the maintenance treatment level (0.4 to 1.3 mEq/L)3.
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