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":"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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Walking the dog daily can contribute positively to the client's recovery by promoting physical activity and potentially reducing stress.
B. The loss of social support due to the best friend moving away can increase stress and negatively impact the client's recovery.
C. Exercising in the morning can also contribute positively to recovery by promoting physical health and potentially reducing stress.
D. Stopping drinking coffee may have various effects on the client's health but is not directly related to recovery from coronary artery bypass surgery unless it exacerbates other issues such as anxiety or withdrawal symptoms.
Correct Answer is A
Explanation
A. Encouraging physical activity during the day has been shown to improve mood and reduce symptoms of depression by increasing endorphin levels and promoting a sense of well-being.
B. Identifying and scheduling alternative group activities for the client may be helpful in reducing social isolation and improving mood but should not replace physical activity.
C. Discouraging the client from expressing feelings of anger is not appropriate, as it may suppress emotions and hinder therapeutic communication. Instead, the nurse should encourage the client to express and explore their emotions in a healthy manner.
D. Keeping a bright light on in the client's room at night may disrupt sleep patterns and exacerbate symptoms of depression, as individuals with depression often have disturbances in their sleep-wake cycle.
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