Nursing Elites

1. A client has been taking lithium for several years with good symptom control. The client presents in the emergency department with blurred vision, tinnitus, and severe diarrhea. Which lithium level should the nurse correlate with these symptoms?

• A. 3.7
• B. 1.7
• C. 2.6
• D. 1.3

Correct answer: B

Rationale: Symptoms such as blurred vision, tinnitus, and severe diarrhea are indicative of lithium toxicity. A lithium level of 1.7 is within the toxic range. When clients present with these symptoms, it is crucial for the nurse to correlate them with elevated lithium levels to ensure timely intervention and prevent further complications.

2. A healthcare professional is assessing a client's use of defense mechanisms. Which statement would indicate to the healthcare professional that the client is using the defense mechanism of projection?

• A. The client accuses others of being angry when it is the client who is angry.
• B. The client refuses to acknowledge a problem despite evidence to the contrary.
• C. The client attributes his own feelings of hostility to others.
• D. The client avoids dealing with painful feelings by focusing on something else.

Correct answer: C

Rationale: Projection is a defense mechanism where individuals attribute their own unacceptable feelings, thoughts, or impulses onto others. In this case, the client is projecting his own feelings of hostility onto others by assuming they possess these feelings instead.

3. A client diagnosed with schizophrenia is prescribed an antipsychotic medication. Which of the following side effects should the nurse not monitor for? Select all that apply.

• A. Tardive dyskinesia
• B. Neuroleptic malignant syndrome
• C. Orthostatic hypotension
• D. Hyperglycemia

Correct answer: A

Rationale: The nurse should not monitor for tardive dyskinesia as it is a potential long-term side effect of antipsychotic medications. However, the nurse should monitor for neuroleptic malignant syndrome, orthostatic hypotension, and hyperglycemia as these are common side effects associated with antipsychotic medications. Tardive dyskinesia is characterized by involuntary movements of the face, tongue, and extremities and may develop after prolonged use of antipsychotic drugs.

4. Which symptom should a healthcare provider identify as typical of the fight-or-flight response?

• A. Pupil dilation
• B. Increased heart rate
• C. Decreased salivation
• D. Decreased peristalsis

Correct answer: B

Rationale: The correct answer is B: Increased heart rate. During the fight-or-flight response, the sympathetic nervous system is activated, causing the release of epinephrine. This hormone triggers an increase in heart rate to supply more blood to the muscles for a rapid response. Pupil dilation occurs to enhance vision in preparation for quick reactions. On the other hand, salivation and peristalsis decrease as the body prioritizes functions necessary for immediate action rather than digestion-related activities. Therefore, choices A, C, and D are incorrect as they do not align with the typical physiological changes associated with the fight-or-flight response.

5. A healthcare provider is providing education to the family of a client who has been diagnosed with bipolar disorder. Which of the following instructions should the healthcare provider include?

• A. The client should avoid all stressful situations.
• B. Encourage the client to get plenty of rest.
• C. Make sure the client takes prescribed medications regularly.
• D. Provide the client with information about support groups.

Correct answer: C

Rationale: The correct answer is C: 'Make sure the client takes prescribed medications regularly.' Consistent medication adherence is crucial in managing the symptoms and stabilizing mood in individuals with bipolar disorder. Choice A is incorrect because avoiding all stressful situations is often not feasible and not the primary treatment approach for bipolar disorder. Choice B, while important, is not as critical as ensuring medication compliance. Choice D is helpful but not as essential as medication adherence for the treatment of bipolar disorder.

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