A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively.
Which action is the priority?

Maintain trust and avoid behaviors that may increase agitation.

Order the client to go to their room & alert security.

Tell the client to sit down or risk isolation and loss of privileges.

Sedate the client after collecting a lithium level.

Answer and Explanation

The Correct Answer is A

Maintain trust and avoid behaviors that may increase agitation. This is because the client is likely experiencing a manic episode, which is characterized by increased activity, rapid speech, and decreased need for sleep. The nurse should use a calm and supportive approach, provide a safe and structured environment, and avoid confrontation or criticism.

Choice B is wrong because ordering the client to go to their room and alerting security would escalate the situation and violate the client’s rights.

Choice C is wrong because telling the client to sit down or risk isolation and loss of privileges would be threatening and punitive, which could increase the client’s agitation and anger.

Choice D is wrong because sedating the client after collecting a lithium level would be premature and inappropriate without a physician’s order and without assessing the client’s vital signs, mental status, and medication history. Lithium is a mood stabilizer that can cause toxicity if the level is too high.

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Correct Answer is ["A","B"]

Explanation

Increased heart rate and decreased blood pressure are common signs of dehydration, as the body tries to compensate for the fluid loss by increasing the heart rate and lowering the blood pressure.

Choice C is wrong because increased temperature is not a typical symptom of dehydration, although it can be a cause of it.

Choice D is wrong because hypoactive muscle responses are not related to dehydration, but rather to neurological or muscular disorders.

Choice E is wrong because alert and oriented is the normal mental status for most people, and dehydration can cause confusion and disorientation in severe cases.

Normal ranges for heart rate and blood pressure vary depending on age, gender, physical activity, and other factors, but generally they are:

Heart rate: 60 to 100 beats per minute for adults
Blood pressure: less than 120/80 mmHg for adults

A. Hemoglobin = 14.2 g/dL. B. Potassium = 4.2 mEq/L. C. Albumin = 2.8 g/dL. D. Creatinine = 0.8 mg/dL.

Correct Answer is C

Explanation

Albumin is a protein that is made by the liver and helps maintain fluid balance in the

body. The normal range for albumin is 3.5 to 5.5 g/dL or 35-55 g/liter. A low albumin level can indicate malnutrition, liver disease, kidney disease, inflammation, or other conditions that affect protein synthesis or loss.

A client diagnosed with Imbalanced Nutrition: Less than Body Requirements would be expected to have a low albumin level due to inadequate protein intake or absorption.

Choice A is wrong because hemoglobin = 14.2 g/dL is within the normal range for males, which is 13.2 to 16.6 g/dL.

Hemoglobin is a protein in red blood cells that carries oxygen throughout the body. A low hemoglobin level can indicate anemia, which can be caused by blood loss, iron deficiency, vitamin B12 deficiency, or other conditions that affect red blood cell production or destruction.

Choice B is wrong because potassium = 4.2 mEq/L is within the normal range for adults, which is 3.5 to 5 mEq/L.

Potassium is an electrolyte that helps regulate fluid balance, nerve impulses, and muscle contractions. A low potassium level can indicate dehydration, diarrhea, vomiting, diuretic use, or other conditions that cause potassium loss. A high potassium level can indicate kidney disease, adrenal insufficiency, acidosis, or other conditions that cause potassium retention.

Choice D is wrong because creatinine = 0.8 mg/dL is within the normal range for adults, which is 0.6 to 1.2 mg/dL.

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A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively. Which action is the priority?

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Naxlex Comprehensive Predictor Exams

A middle-aged adult client with nausea and vomiting for three days presents to the emergency room. Which findings should the nurse expect to assess in a client diagnosed with dehydration? Select all that apply.

Correct Answer is ["A","B"]

Explanation

Which serum laboratory test result should the nurse expect for a client diagnosed with Imbalanced Nutrition: Less than Body Requirements?

Correct Answer is C

Explanation

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A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively.
Which action is the priority?