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 D

Explanation

A. Hepatitis B infection is not a contraindication for prescribing bupropion for smoking cessation.
B. Hypothyroidism is not a contraindication for prescribing bupropion for smoking cessation.

C. Knee arthroplasty 1 month ago does not contraindicate the use of bupropion for smoking cessation.
D. Bupropion is contraindicated in individuals with a recent head injury due to the increased risk of seizures associated with this medication. Therefore, the nurse should report this finding to the provider.

A. Report the information to local authorities. B. Avoid reporting the information provided by the client because it is confidential. C. Tell risk management about the client's plan to hurt their partner. D. Notify the provider that the client should stay longer at the facility to work on anger management.

Correct Answer is A

Explanation

A. Safety is paramount, and if a client expresses intent to harm someone, it must be taken seriously and reported to local authorities to prevent harm and ensure the safety of the potential victim.
B. Confidentiality is important, but when there is a threat to harm others, the duty to warn and protect overrides confidentiality.
C. While informing risk management may be appropriate in some situations, when there is an imminent threat of harm, immediate action is necessary, which includes reporting to local authorities.
D. Delaying discharge to work on anger management may not be sufficient to ensure the safety of the potential victim. Reporting the threat to local authorities is necessary to prevent harm.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which of the following assessment findings in the client's history should the nurse report to the provider?

Correct Answer is D

Explanation

A nurse is caring for a client who has antisocial personality disorder and reports planning to hurt their partner upon discharge. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

An older adult client is brought to the mental health clinic by her daughter. The daughter reports that her mother is not eating and seems uninterested in routine activities. The daughter states, "I'm so worried that my mother is depressed." Which of the following responses should the nurse make?

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 is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?

A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take?

A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

A home health nurse is visiting a client who is recovering from coronary artery bypass surgery and reports experiencing stress. The nurse should determine that which of the following factors might interfere with the client's recovery?

A nurse is caring for a client who has right-sided hemiplegia following a recent stroke. Which of the following questions should the nurse ask to determine the client's ability to cope?

A nurse is reviewing the day 5 vital signs and nurses' notes. Exhibits A nurse is evaluating the client's response to treatment. Select the 4 findings that indicate the client is progressing with their plan of care.