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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Correct Answer is C

Explanation

A. Orientation to person, place, and time is important for assessing mental status but may not necessarily indicate the need for restraint removal.
B. Self-harm threats should be taken seriously but may require further assessment and intervention rather than immediate restraint removal.
C. The ability to follow commands indicates a level of cooperation and self-control, which may warrant removal of restraints as the client can potentially be managed without them.
D. Refusal to take medication may necessitate further intervention but may not directly indicate the need for restraint removal unless it poses an immediate risk to the client's safety.

A. Buprenorphine B. Bupropion C. Disulfiram D. Chlordiazepoxide

Correct Answer is D

Explanation

A. Buprenorphine is not typically indicated for alcohol withdrawal; it is primarily used in the management of opioid dependence.
B. Bupropion is an antidepressant medication and is not indicated for the treatment of acute alcohol withdrawal.
C. Disulfiram is used as a deterrent to alcohol consumption in individuals who have achieved abstinence and is not indicated for acute alcohol withdrawal.
D. Chlordiazepoxide is a benzodiazepine medication commonly used to manage alcohol withdrawal symptoms, such as anxiety and agitation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A nurse is reviewing new prescriptions for a client who is experiencing acute manifestations of alcohol withdrawal. Which of the following medications should the nurse expect the provider to prescribe for this client?

Correct Answer is D

Explanation

A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?

A nurse is teaching a client who is to start taking fluoxetine. The nurse should instruct the client that which of the following supplements Interacts adversely with fluoxetine?

A nurse in a mental health facility is admitting a client. Exhibits A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.

A nurse is talking to a client following a group therapy session. The client tells the nurse that one of the other clients in the group made an inappropriate comment. Which of the following responses should the nurse make?

A nurse is planning care for a client who has borderline personality disorder. Which of the following interventions should the nurse plan to include to assist the client with impaired social interactions with others?

A nurse is caring for an adult client who has been placed in physical restraints due to aggressive behavior. Which of the following actions should the nurse take?

A nurse is caring for a client who states, "Things will never work out." Which of the following responses should the nurse make?