A nurse on a mental health unit is caring for a client.
Nurses' Notes
Day 1, 1300:
Client admitted following a suicide attempt. Client's family reports client has not left bedroom in 1 week. Client previously. diagnosed with bipolar disorder.
Client reports feeling excessively tired and light-headed. Allergies: Client's family reports allergy to SSRIS (angioedema) and penicillin (anaphylaxis).
1600:
Client has been sleeping in their room since admission. Flat affect noted.
For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.
Low-sodium diet
Potassium 40 mEq PO daily
Initiate suicide precautions
Fluoxetine 20 mg PO daily
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}
A. Low-sodium diet Contraindicated: A low-sodium diet can decrease lithium elimination, leading to increased lithium levels and risk of toxicity in lithium users. B. Potassium 40 mEq PO daily Anticipated: Potassium supplementation may be needed to prevent hypokalemia, which can occur due to lithium-induced polyuria or diuretic use. C. Initiate suicide precautions Anticipated: Suicide precautions are essential for any client who has attempted or expressed suicidal ideation, especially during the depressive phase of bipolar disorder. D. Fluoxetine 20 mg PO daily Contraindicated: Fluoxetine is an SSRI antidepressant, which can cause angioedema in clients who are allergic to SSRIs. Additionally, fluoxetine can trigger manic episodes or increase suicidal risk in clients with bipolar disorder.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A is incorrect because tinnitus, or ringing in the ears, is not an adverse effect of captopril, but rather a symptom of other conditions such as ear infection, noise exposure, or medication toxicity.
B is correct because cough is a serious adverse effect of captopril, which is an angiotensin-converting enzyme (ACE) inhibitor that can cause angioedema, or swelling of the airways.
C is incorrect because polyuria, or excessive urination, is not an adverse effect of captopril, but rather a symptom of other conditions such as diabetes mellitus, diabetes insipidus, or diuretic use.
D is incorrect because blurred vision is not an adverse effect of captopril, but rather a symptom of other conditions such as eye strain, refractive error, or cataract.
Correct Answer is B, A, D, C
Explanation
B. Inspection is the first step in an abdominal assessment because it allows the nurse to observe the shape, size, symmetry, contour, and movement of the abdomen. Inspection also helps to identify any abnormalities such as scars, lesions, masses, or distension.
A. Auscultation is the second step in an abdominal assessment because it allows the nurse to listen to the bowel sounds and vascular sounds of the abdomen. Auscultation should be performed before palpation or apercussion because these maneuvers could alter the sounds.
D. Percussion is the third step in an abdominal assessment because it allows the nurse to elicit sounds from different organs and structures in the abdomen. Percussion helps to determine the size, location, density, and consistency of the organs and to detect any fluid or air accumulation.
C. Palpation is the last step in an abdominal assessment because it allows the nurse to feel the texture, temperature, tenderness, and masses of the abdomen. Palpation should be performed gently and carefully to avoid causing pain or injury to the client.
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