The nurse should monitor the client for signs and symptoms of digoxin toxicity if the laboratory report reflects a serum:
sodium of 133 mg/dl.
glucose of 110 mg/dl.
potassium of 3.0 mEq/L.
calcium of 9.0 mg/dl.
The Correct Answer is C
C. Digoxin toxicity is a serious condition that can occur when there is too much digoxin in the body. It can lead to life-threatening cardiac dysrhythmias. One of the risk factors for digoxin toxicity is low blood levels of potassium, or hypokalemia.
A. Electrolyte imbalances, including hyponatremia (low sodium levels), can contribute to digoxin toxicity. However, a sodium level of 133 mg/dl alone does not directly indicate digoxin toxicity.
B. Blood glucose levels within the normal range (80-120 mg/dl) would not directly indicate digoxin toxicity.
D. Calcium levels within the normal range (8.5-10.5 mg/dl) do not directly indicate digoxin toxicity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Splitting is characterized by viewing people and situations in extremes, either all good or all bad, without recognizing the complexity that usually exists in most circumstances. This black-and-white thinking can lead to rapidly shifting perceptions of others, as seen in the client's sudden change from idealizing the nurse to devaluing them.
A. Denial is a defense mechanism where the individual refuses to accept reality or acknowledge an aspect of reality that is apparent to others. In this scenario, the client is not denying any aspect of reality.
B. Separation-individuation is a developmental process where individuals establish autonomy and a sense of self separate from others, particularly from primary caregivers. This process is more relevant in infancy and early childhood.
D. Reaction formation is a defense mechanism where an individual behaves in a manner opposite to their true feelings or impulses. In this scenario, the client's expression of hatred towards the nurse does not appear to be a case of reaction formation, as there is no indication that the client actually harbors feelings of care or admiration towards the nurse.
Correct Answer is C
Explanation
C. Acceptance and trust create a sense of safety and security for the client within the therapeutic relationship. When the client feels accepted and valued by the nurse, they are more likely to feel comfortable opening up and engaging in the therapeutic process.
A. Establishing a therapeutic alliance provides a safe and supportive environment for the client to express their feelings without fear of judgment or rejection. However, therapeutic alliance goes beyond this.
B. Therapeutic activities can indeed provide an outlet for tension and stress but the establishment of a therapeutic alliance goes beyond engaging in specific activities.
D. Focusing on positive behaviors and strengths can contribute to building self-esteem. However, the establishment of a therapeutic alliance involves more than just focusing on behaviors.
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