A nurse is caring for an older adult client who is postoperative.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to collect data about the client’s progress.

Answer and Explanation

The Correct Answer is []

Potential Condition: Delirium The client’s symptoms such as disorientation to time and place, disorganized thinking, lack of attention, rambling speech, and changes in behavior that began the prior evening suggest the client is most likely experiencing delirium12. Delirium is common in older adults who are postoperative and can be triggered by factors such as dehydration, infection, and certain medications.

Actions to Take:

Choice A: Monitor client’s fluid intake and output The client has refused to eat or drink since the previous day and has a significant difference between intake (250 mL) and output (2,500 mL), suggesting possible dehydration3. Monitoring the client’s fluid intake and output can help assess the client’s hydration status and the effectiveness of interventions such as IV fluid administration.

Choice E: Encourage family members to stay with the client Family members can provide a familiar and reassuring presence, which can help orient the client and potentially reduce agitation and restlessness. They can also provide valuable information about the client’s normal behavior and any changes they have noticed.

Parameters to Monitor:

Choice A: Fall risk The client is attempting to get out of bed without assistance, which increases the risk of falls4. Monitoring the client’s mobility and implementing fall prevention strategies is crucial.

Choice E: Sleep-wake cycle The client has been awake most of the night, indicating a disruption in the sleep-wake cycle5. Monitoring the client’s sleep patterns can provide information about the progression of delirium and the effectiveness of interventions.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A: Sodium Level
Lithium can affect sodium levels in the body, but monitoring sodium levels is not the primary focus when assessing for lithium toxicity or adverse effects. Lithium can cause hyponatremia (low sodium levels) due to its effects on the kidneys and its ability to interfere with sodium reabsorption. However, sodium levels are not the most critical laboratory value to monitor for lithium therapy. Instead, healthcare providers focus on lithium levels in the blood to ensure they are within the therapeutic range, which is typically 0.6 to 1.2 mEq/L.

Choice B: Liver Enzymes
Monitoring liver enzymes is essential for medications that are metabolized by the liver and can cause hepatotoxicity. Lithium is not primarily metabolized by the liver; it is excreted unchanged by the kidneys. Therefore, liver enzymes are not a primary concern when monitoring for lithium's adverse effects. However, it is still important to monitor kidney function, as lithium can cause nephrotoxicity.

Choice C: Uric Acid
Lithium can increase uric acid levels in the blood, leading to hyperuricemia and potentially causing gout. Monitoring uric acid levels is important to prevent and manage these potential adverse effects. Elevated uric acid levels can lead to the formation of urate crystals in the joints, causing pain and inflammation. Therefore, healthcare providers often monitor uric acid levels in patients taking lithium to prevent complications related to hyperuricemia.

Choice D: Erythrocyte Sedimentation Rate
The erythrocyte sedimentation rate (ESR) is a nonspecific marker of inflammation and is not directly related to lithium therapy. While ESR can be elevated in various conditions, including infections, autoimmune diseases, and chronic inflammatory conditions, it is not a primary laboratory value to monitor for lithium's adverse effects. Monitoring ESR would not provide specific information about lithium toxicity or its impact on the body.

A. Explain the use of response prevention to the client. B. Administer an antianxiety medication. C. Discuss the benefits of relaxation exercises with the client. D. Calculate the client's score on the Hamilton Rating Scale for Anxiety.

Correct Answer is A

Explanation

Choice A Reason:
Explaining the use of response prevention to the client is crucial as it is a primary therapeutic approach for managing obsessive-compulsive disorder (OCD). Response prevention, part of Exposure and Response Prevention (ERP) therapy, involves exposing the client to anxiety-provoking stimuli and preventing the compulsive response. This method helps the client gradually reduce their anxiety and compulsive behaviors by learning to tolerate the distress without performing the compulsive act. ERP is considered the gold standard treatment for OCD and is highly effective in reducing symptoms.

Choice B Reason:
Administering an antianxiety medication can be beneficial for managing symptoms of anxiety in clients with OCD. Common medications include selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, sertraline, and fluvoxamine. However, medication alone is not the first-line treatment for OCD. It is often used in conjunction with cognitive-behavioral therapy (CBT), specifically ERP, to achieve the best outcomes. Therefore, while important, it is not the initial action the nurse should take.

Choice C Reason:
Discussing the benefits of relaxation exercises with the client can help manage anxiety symptoms associated with OCD. Techniques such as deep breathing, mindfulness meditation, and progressive muscle relaxation can be effective in reducing stress and anxiety. However, these methods are supportive measures and do not directly address the core symptoms of OCD. They are best used as complementary strategies alongside primary treatments like ERP.

Choice D Reason:
Calculating the client's score on the Hamilton Rating Scale for Anxiety (HAM-A) is useful for assessing the severity of anxiety symptoms. The HAM-A is a clinician-rated scale that measures both psychic and somatic anxiety through 14 items. While this assessment is valuable for monitoring treatment progress and tailoring interventions, it is not the immediate priority when initiating care for a client with OCD. The primary focus should be on implementing therapeutic strategies that directly target OCD symptoms.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has bipolar disorder and has a new prescription for lithium. To address possible adverse effects, the nurse should include that which of the following laboratory values will be monitored while the client is taking this medication?

Correct Answer is C

Explanation

A nurse is caring for a newly admitted client who has obsessive-compulsive disorder. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is preparing to administer disulfiram 375 mg PO once daily. Available is disulfiram 250 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is reinforcing teaching with a newly licensed nurse about the Patient Self-Determination Act (PSDA). Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A nurse is collecting data from a client who has bulimia nervosa. Which of the following findings should the nurse expect?

A nurse is caring for a client who is receiving acute care for the treatment of a substance use disorder. With which of the following actions is the nurse demonstrating the ethical principle of veracity?

A nurse is collecting data from a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (Select all that apply)

A nurse on a mental health unit is assisting with developing an in-service for staff members about legal issues. Which of the following examples should the nurse include as an example of libel?

A nurse is assisting with teaching a group of older adult clients about behavioral expectations. Which of the following actions should the nurse take to help eliminate barriers to learning?