A nurse on an inpatient mental health unit is admitting a client.

Exhibits

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

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"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 worsening: polyuria is a sign of lithium toxicity.

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

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"A"},"H":{"answers":"A"}}

Explanation

Electroconvulsive therapy (ECT) is contraindicated in the acute phase of alcohol withdrawal due to the increased risk of seizure activity.

Group therapy is anticipated as it can provide peer support, coping strategies, and psychoeducation, which are beneficial for individuals with alcohol use disorder.

Performing the Alcohol Use Disorders Identification Test (AUDIT) is anticipated to assess the severity of alcohol use disorder and guide treatment planning.

Methadone may be anticipated as part of the treatment plan for managing alcohol withdrawal symptoms and cravings.

Ordering a complete blood count and basic metabolic profile is anticipated to assess the client's overall health status and detect any abnormalities related to alcohol use.

A nutritional consult is anticipated to address the client's weight loss and minimal appetite, providing dietary recommendations and support.

Propranolol may be anticipated to manage autonomic symptoms of alcohol withdrawal, such as tremors and tachycardia.

Diazepam may be anticipated to manage alcohol withdrawal symptoms, including agitation, anxiety, and seizures.

A. "It'll be a long time before I'm happy again." B. "I don't know how I could cope if I didn't have my family's support." C. "I feel like I'm angry at the whole world right now." D. "I don't feel anything but numbness anymore."

Correct Answer is D

Explanation

A. This statement reflects a realistic acknowledgment of the grieving process and does not necessarily indicate clinical depression.
B. Expressing dependence on family support is a common coping mechanism during grief and does not necessarily indicate clinical depression.
C. Feelings of anger are common during the grieving process and do not necessarily indicate clinical depression.
D. Feeling numb or anhedonic, the inability to experience pleasure, is a symptom commonly associated with clinical depression and should be reported to the provider for further evaluation and intervention.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing alcohol withdrawal. Exhibits A nurse is planning care for a client who has alcohol use disorder. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"A"},"H":{"answers":"A"}}

Explanation

A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression?

Correct Answer is D

Explanation

A nurse is caring for a client who has bulimia nervosa. Which of the following interventions should the nurse include in the client's plan of care?

A nurse is creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the nurse include in the plan?

A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?

A nurse is leading a crisis intervention group for adolescents who witnessed the suicide of a classmate. Which of the following actions should the nurse take first?

A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a pass during lunchtime. Which of the following assessments should the nurse perform?

A nurse is planning care for an adolescent who has autism spectrum disorder. Which of the following outcomes should the nurse include in the plan of care?

A nurse in an emergency department is assessing a client who reports recently using cocaine.Which of the following clinical manifestations should the nurse expect?