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.
Blurred vision
Blood pressure
Urine amount and color
Lithium level
Gait when ambulating
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A. Although extending the client's stay may allow for further treatment, it is not the most immediate or necessary action in this situation. The priority is ensuring safety, which requires reporting the threat to appropriate authorities.
B. Confidentiality is essential in healthcare, but it does not override the obligation to report threats of harm to others. The nurse must prioritize the safety of the potential victim, which requires breaching confidentiality to report the threat.
C. While risk management may be involved later, the nurse’s first responsibility is to report the
imminent threat of harm to the appropriate authorities to prevent harm to the partner.
D. The nurse has a legal and ethical obligation to report any threats of harm to others. By notifying local authorities, the nurse helps prevent potential harm to the partner, ensuring their safety.
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