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.

Blurred vision

Blood pressure

Urine amount and color

Lithium level

Gait when ambulating

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Blurred vision:

Indicates Potential Worsening: Blurred vision is a common side effect of lithium toxicity, which the client has based on the elevated lithium level of 1.9 mEq/L (normal is less than 1.5 mEq/L). It is considered a potential worsening sign, as it suggests the client's lithium levels may be too high, leading to side effects like visual disturbances.

Blood pressure:

Indicates Potential Improvement: The blood pressure is relatively stable, with a slight drop from 114/64 mm Hg (Day 1) to 98/56 mm Hg (Day 2). While there is a decrease, it is still within a normal range, indicating no immediate concern. It is important to monitor blood pressure, but a small decrease can be expected in some cases, especially in the context of medication or rest.

Urine amount and color:

Indicates Potential Improvement: The client reports voiding a large amount of dilute yellow urine. This is a positive sign, as it indicates that the kidneys are functioning properly and that the client is adequately hydrated. The color and volume of urine are both normal and suggest no issues with fluid balance or kidney function.

Lithium level:

Indicates Potential Worsening: A lithium level of 1.9 mEq/L is above the therapeutic range of less than

1.5 mEq/L and indicates lithium toxicity. This is a worsening sign, as elevated lithium levels can lead to symptoms such as nausea, tremors, uncoordinated gait, and blurred vision (all of which are present in this client). The nurse should prioritize addressing this issue to prevent further complications.

Gait when ambulating:

Indicates Potential Worsening: The client is noted to have an uncoordinated gait, which is another sign of lithium toxicity. Incoordination and tremors are common signs of lithium toxicity, and unsteady gait can increase the risk of falls. This indicates that the client's condition may be worsening due to the elevated lithium level and the associated side effects.

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Correct Answer is A

Explanation

A. This statement is an example of generalizing, where the client makes a broad statement without recognizing specific instances or nuances. "Always criticizing" is an overgeneralization and may not accurately reflect the situation.
B. Manipulating involves influencing or controlling others in an indirect or deceptive way. The statement does not suggest manipulation but rather a complaint about perceived behavior.
C. Distracting communication occurs when someone diverts attention away from the topic. The statement does not exhibit this behavior; it is a direct expression of concern.
D. Placating involves trying to calm someone down or please them to avoid conflict. The client's statement is more accusatory than an attempt to placate.

A. "Therapy is often scheduled during my daily meditation time." B. "My faith gives me hope during difficult times." C. "I gain comfort from meditation." D. "My spiritual advisor has increased visits since I became ill."

Correct Answer is D

Explanation

A. While this statement indicates a potential scheduling conflict, it does not directly suggest spiritual distress. The client is simply reporting a situation where their spiritual practice is being interrupted.
B. This statement reflects spiritual strength and resilience. The client expresses that their faith is a source of comfort and hope, which is not an indicator of spiritual distress.
C. This statement indicates that the client uses meditation as a coping mechanism, which suggests a healthy spiritual practice and not spiritual distress.
D. This statement suggests that the client may be experiencing spiritual distress, as the increased visits from the spiritual advisor could indicate a need for additional spiritual support during a difficult time.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's communication patterns. The client states, "My partner is always criticizing me." This statement is an example of which of the following types of dysfunctional communication?

Correct Answer is A

Explanation

A nurse is assessing the spiritual beliefs of a client. Which of the following client statements indicates spiritual distress?

Correct Answer is D

Explanation

A nurse is talking with a newly licensed nurse about client rights while admitted to a mental health facility. Which of the following information should the nurse include? (Select all that apply.)

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Patient Data Exhibits When educating the client about their medication, the nurse should teach the client that there is risk for dropdown due to dropdown