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 D
Explanation
A. Informing the client about confidentiality rights typically occurs during the orientation phase of the therapeutic relationship, not the working phase.
B. Establishing boundaries between the nurse and the client is an ongoing process that occurs throughout the therapeutic relationship, not just during the working phase.
C. Setting short- and long-term objectives for the future typically occurs during the orientation phase and continues throughout the therapeutic relationship, not just during the working phase.
D. During the working phase of the therapeutic relationship, the nurse and client collaborate to achieve the goals identified during the orientation phase. The nurse evaluates the client's progress toward these goals and adjusts interventions as necessary to promote therapeutic outcomes.
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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