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).

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale: Remaining calm and using a matter-of-fact approach helps provide a sense of security and reduces anxiety in the client during admission.
Choice B rationale: Assisting the client in developing alternative coping skills is important but may not be the first action during the initial admission process.

Choice C rationale: Administering a sedative may be considered if the client's anxiety is severe, but understanding and addressing the underlying cause of anxiety is the priority.
Choice D rationale: Asking the client why she is anxious may be appropriate, but the initial focus is on providing a calming and supportive environment during admission.

A. Thiamine. B. Chlordiazepoxide. C. Clonidine. D. Carbamazepine.

Correct Answer is A

Explanation

Choice A rationale: Thiamine (vitamin B1) is the appropriate medication for Wernicke Korsakoff syndrome, as it addresses thiamine deficiency associated with chronic alcohol use, which can contribute to neurological symptoms.

Choice B rationale: Chlordiazepoxide is a benzodiazepine used for alcohol withdrawal symptoms but does not address the underlying thiamine deficiency in Wernicke Korsakoff syndrome.

Choice C rationale: Clonidine is not indicated for the treatment of Wernicke-Korsakoff syndrome; it is primarily used for managing withdrawal symptoms in opioid or alcohol dependence.

Choice D rationale: Carbamazepine is not the appropriate medication for Wernicke Korsakoff syndrome; it is commonly used for mood stabilization in conditions like bipolar disorder.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During admission to the psychiatric unit, a client is extremely anxious and reports being worried about the sun coming up the next day. Which intervention is most important for the nurse to implement during the admission process?

Correct Answer is A

Explanation

A client with chronic alcohol dependence is diagnosed with Wernicke-Korsakoff syndrome. The client is experiencing memory loss and confusion. Which medication should the nurse administer to help alleviate the client's symptoms?

Correct Answer is A

Explanation

A client who is experiencing a severe level of anxiety and reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?

A client who experiences memory loss is diagnosed with Wernicke encephalopathy caused by alcohol addiction. Which intervention is most important for the nurse to implement?

A middle-aged female client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse, "I want to find out why these people are stalking me!" Which response should the nurse provide?

Two days after being admitted with alcohol withdrawal, a client has constant liquid stools and abdominal cramping. The emesis and stool are hemoccult positive. The client is confused and refusing to take oral medication. Which action should the nurse implement first?

A client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because of a stalker. Which action is most important for the nurse to take?

The nurse is planning the care for a client who is hospitalized with a bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? Select all that apply.