The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?
Five-pound (2.3 kg) weight gain.
Nausea and vomiting.
Short-term memory loss.
Depressed affect.
The Correct Answer is B
Choice A rationale:
A five-pound weight gain in a client taking lithium carbonate is significant. however, the timeframe of the weightgain is to be known. Choice B rationale:
Nausea and vomiting are known side effects of lithium that should be reported as they can cause electrolyte imbalance.
Choice C rationale:
Short-term memory loss is a potential side effect of lithium, but it may not require immediate reporting unless it significantly affects the client's daily functioning or is associated with other concerning symptoms.
Choice D rationale:
A depressed affect is a symptom that should be addressed as part of the client's ongoing psychiatric care, but it may not warrant immediate reporting unless it is severe and requires a change in the treatment plan. The priority in this case is the potential lithium toxicity indicated by the weight gain.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Using an incentive spirometer is not directly related to the post-TUNA discharge instructions for a client with BPH. Incentive spirometry is typically used to improve lung function and prevent respiratory complications.
Choice B rationale:
Monitoring the urinary stream for a decrease in output may be important, but it is a general instruction that may not be specific to the TUNA procedure. The primary focus after TUNA is often on monitoring for complications related to the procedure.
Choice C rationale:
Reporting when hematuria (blood in the urine) becomes pink-tinged is important. While some degree of hematuria is expected after TUNA, a change in color to pink or any other concerning changes should be reported to the healthcare provider as it could indicate complications.
Choice D rationale:
There is typically no need to restrict physical activities after a TUNA procedure. In fact, healthcare providers often encourage patients to resume normal activities gradually unless otherwise instructed due to specific complications.
Correct Answer is ["A","B","C"]
Explanation
The assessment findings that require immediate follow-up by the nurse are: muscle cramps, tingling sensation in arms and legs, and lightheadedness.
These are signs of electrolyte imbalance, which can be caused by missed dialysis sessions, dehydration, or infection. Electrolyte imbalance can lead to serious complications such as cardiac arrhythmias, seizures, or coma.
The nurse should monitor the client's vital signs, neurological status, and cardiac rhythm, and notify the physician for further orders. The nurse should also assess the client's fluid status, hydration, and nutritional intake, and provide education on the importance of adhering to the dialysis schedule and dietary restrictions.
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