The nurse is completing the admission assessment of an adolescent client who is underweight and admitted to a psychiatric unit with a diagnosis of depression. Which finding requires notification to the healthcare provider?
Reference Range:
Potassium (K+) [3.5 to 5.0 mEq/L or 3.5 to 5.0 mmol/L]
White Blood Cell (WBC) [5000 to 10,000/mm3 or 5 to 10 x 109/L]
Body mass index of 21.
Blood pressure of 110/70 mm Hg.
Potassium level of 2.9 mEq/dl (2.9 mmol/L).
WBC of 10,000/mm3 (10 x 109/L).
The Correct Answer is C
Choice A rationale: A body mass index (BMI) of 21 is within the normal range and does not require immediate notification to the healthcare provider.
Choice B rationale: A blood pressure of 110/70 mm Hg is within the normal range for an adolescent and does not require immediate notification.
Choice C rationale: A potassium level of 2.9 mEq/dL (2.9 mmol/L) is below the normal range (hypokalemia) and requires notification to the healthcare provider due to the potential for adverse effects on cardiac and neuromuscular function.
Choice D rationale: A WBC of 10,000/mm3 (10 x 109/L) falls within the normal range and does not require immediate notification.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: The client should avoid all alcohol, not limit consumption to one drink per day.
Choice B rationale: Avoiding all alcohol-containing products while on disulfiram is crucial to prevent a severe reaction called the disulfiram-alcohol reaction.
Choice C rationale: Operating heavy machinery is not a specific concern with disulfiram; avoiding alcohol is the primary focus.
Choice D rationale: Disulfiram can be taken with or without food, and taking it on an empty stomach is not necessary.
Correct Answer is B
Explanation
Choice A rationale: While assessing for symptoms of cocaine withdrawal is important, educating the client about the purpose and side effects of the medication is the priority when initiating new pharmacological treatment.
Choice B rationale: Educating the client about the purpose and side effects of the medication promotes understanding and adherence to the treatment plan, addressing the client's cravings.
Choice C rationale: Encouraging the client to take the medication as prescribed is important, but educating them about the medication takes precedence.
Choice D rationale: Determining when the client last used cocaine is relevant but does not directly address the education needed for medication management.
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