A nurse on an inpatient mental health unit is admitting a client.
The nurse is reviewing the client's medical record at 0830 on day 2 of admission.
For each finding, click to specify whether the finding indicates a potential improvement in or a potential worsening of the client's condition.
Blood pressure
Gait when ambulating
Lithium level
Urine amount and color
Blurred vision
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}
Blood pressure Potential worsening: The blood pressure dropped from 114/64 mm Hg on Day 1 to 98/56 mm Hg on Day 2, indicating a potential worsening as it decreased.
Gait when ambulating - Potential worsening: The client's gait was noted to be uncoordinated when ambulating to the bathroom on Day 2, suggesting a potential worsening in motor coordination or balance.
Lithium level Potential worsening: The lithium level increased from 1.9 mEq/L on Day 2, exceeding the therapeutic range (less than 1.5 mEq/L), indicating a potential worsening due to lithium toxicity.
Urine amount and color - Potential improvement: The client voided a large amount of dilute yellow urine on Day 2, suggesting improved hydration status and renal function.
Blurred vision Potential worsening: The client reports blurred vision and frequently rubs their eyes on Day 2, indicating a potential worsening of visual acuity or ocular health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This choice demonstrates an understanding of the importance of utilizing effective coping mechanisms.
B. Depending solely on a partner to plan daily activities may indicate dependence rather than self-care.
C. Remaining in bed excessively can perpetuate depressive symptoms and hinder recovery.
D. Avoiding discussing upsetting events may prevent processing emotions and hinder progress in therapy.
Correct Answer is C
Explanation
A. Meeting one's own needs without manipulating others may be a desirable outcome but is not specific to the core deficits of autism spectrum disorder.
B. Acknowledging that delusions are not real is more relevant to psychotic disorders rather than autism spectrum disorder.
C. Initiating social interactions with caregivers is an appropriate outcome for individuals with autism spectrum disorder, as it reflects improved social communication skills and social engagement.
D. Individuals with autism spectrum disorder may have difficulty understanding and responding to peer pressure, so changing behavior as a result of peer pressure may not be a realistic or desirable outcome.
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