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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Free Nursing Study Resources

Correct Answer is ["B","C","D","E","F"]

Explanation

A. Smoking history: Although the client quit smoking over 20 years ago, there is no immediate concern with their smoking history in this admission. The focus is on the current alcohol-related issues, as smoking history does not have a direct, immediate impact on the client's current condition.
B. Client's recent consumption of alcohol: The client has a history of alcohol use disorder and has been drinking continuously since the death of their parents. Monitoring alcohol consumption and its effects is crucial for evaluating withdrawal symptoms and preventing complications like delirium tremens, which can occur in severe alcohol withdrawal.
C. Blood alcohol level: Since the client has consumed alcohol recently (within the past 2 hours), it is important to assess their blood alcohol level to determine the extent of intoxication and potential risks associated with alcohol withdrawal. This helps guide immediate management and interventions.
D. Client's recent loss: The death of the client's parents is a significant stressor that likely contributed to the relapse in alcohol use. This emotional distress should be addressed as part of the care plan, as it may be influencing the client's mental and emotional state, which can impact their recovery process.

E. Respiratory assessment: The client has a respiratory rate of 10/min, which is low and could be indicative of respiratory depression, especially if the client is intoxicated or if withdrawal symptoms are imminent. Monitoring respiratory status is important to ensure adequate oxygenation and detect early signs of respiratory distress.
F. Neurological assessment: The client is intoxicated and exhibiting slurred speech, which suggests neurological impairment. It is important to monitor the client's neurological status for any signs of complications such as confusion, altered consciousness, or the onset of alcohol withdrawal seizures or delirium.
G. Cardiac assessment: The client has a normal heart rate and rhythm upon initial assessment, and there is no indication of cardiovascular distress. While cardiovascular monitoring is important, the client's current condition does not show any immediate signs that require further follow-up.
H. Gastrointestinal assessment: Although the client reports weight loss and a minimal appetite, these findings are likely related to their alcohol use disorder and could be addressed as part of the ongoing management of the condition. However, this does not require immediate follow-up compared to the more urgent issues related to intoxication and withdrawal.
I. Genitourinary assessment: The client reports no known problems, and there are no immediate concerns about their genitourinary system. This assessment is less of a priority at this time compared to monitoring for alcohol-related issues.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

Correct choices are metoclopramide then propranolol Rationale

1. Metoclopramide:

The first choice should be metoclopramide, an antiemetic, because the client is experiencing vomiting. Vomiting is a common symptom of alcohol withdrawal, which can be aggravated by nausea.

Metoclopramide can help manage the vomiting by promoting gastric emptying and alleviating nausea, thus improving the client's comfort and preventing further complications from dehydration and electrolyte imbalances due to vomiting.

2.Propranolol:

After addressing the vomiting, the nurse should administer propranolol. This beta-blocker is useful for managing alcohol withdrawal symptoms such as elevated heart rate and blood pressure, which the client is exhibiting. On Day 2, the client's blood pressure has increased significantly (198/86 mm Hg), and their heart rate has risen to 116/min, which suggests sympathetic hyperactivity typical of alcohol withdrawal. Propranolol can help reduce these vital sign changes, manage agitation, and prevent complications such as cardiovascular instability.

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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 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.

Correct Answer is ["B","C","D","E","F"]

Explanation

A nurse is caring for a client who is experiencing alcohol withdrawal. Exhibits Complete the following sentence by using the lists of options. The nurse should first administer dropdown followed by administering dropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

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