Nursing Elites

1. A male patient calls to tell the nurse that his monthly lithium level is 1.7 mEq/L. Which nursing intervention will the nurse implement initially?

• A. Reinforce that the level is above the therapeutic range.
• B. Instruct the patient to hold the next dose of medication and contact the prescriber.
• C. Advise the patient to go to the hospital emergency room immediately.
• D. Inform the patient about the possibility of seizures and appropriate precautions.

Correct answer: B

Rationale: A lithium level of 1.7 mEq/L is above the therapeutic range, indicating a potential risk of toxicity. The initial nursing intervention should be to instruct the patient to hold the next dose of medication and promptly contact the prescriber for further guidance and management. This action aims to prevent adverse effects and ensure the patient's safety by addressing the elevated lithium level appropriately.

2. The healthcare provider is providing medication education to a patient who has been prescribed lithium to stabilize mood. Which early signs and symptoms of toxicity should the healthcare provider stress to the patient? Select one that does not apply.

• A. Increased attentiveness
• B. Getting up at night to urinate
• C. Improved vision
• D. An upset stomach for no apparent reason

Correct answer: C

Rationale: Early signs of lithium toxicity include gastrointestinal upset, tremors, increased urination, and increased thirst. Improved vision is not a typical early sign of lithium toxicity and should be ruled out as a symptom to watch for.

3. When providing care for 10-year-old Harper diagnosed with posttraumatic stress disorder (PTSD), which goal should be addressed initially?

• A. Harper will be able to identify feelings through the use of play therapy.
• B. Harper and her parents will have access to protective resources available through social services.
• C. Harper will demonstrate the effective use of relaxation techniques to restore a sense of control over disturbing thoughts.
• D. Harper and her parents will demonstrate an understanding of the personal human response to traumatic events.

Correct answer: C

Rationale: The initial goal when caring for a child with PTSD like Harper is to address restoring a sense of control over disturbing thoughts by teaching relaxation techniques. This approach helps the child manage their distressing emotions and promotes a feeling of empowerment in dealing with their condition.

4. When attempting to determine a teenager's mental health resilience, what assessment question should the nurse ask that is not applicable?

• A. How did you cope when your father deployed with the Army for a year in Iraq?
• B. Who did you go to for advice while your father was away for a year in Iraq?
• C. How do you feel about talking to a mental health counselor?
• D. Why would you think that is a better option than meeting with me?

Correct answer: D

Rationale: Assessing a teenager's mental health resilience involves exploring coping mechanisms, support systems, and attitudes towards seeking help. Option D is not relevant to assessing resilience but rather focuses on the comparison between seeking advice from a counselor versus the nurse, which doesn't directly gauge the teenager's resilience.

5. Which is a correct evaluation of the new psychiatric nurse's statement regarding a client's use of defense mechanisms?

• A. Defense mechanisms can be self-protective responses to stress and need not be eliminated.
• B. Defense mechanisms are a maladaptive attempt by the ego to manage anxiety and should always be eliminated.
• C. Defense mechanisms, used by individuals with weak ego integrity, should be discouraged but not eliminated.
• D. Defense mechanisms cause disintegration of the ego and should be fostered and encouraged.

Correct answer: A

Rationale: The correct evaluation is that defense mechanisms can be self-protective responses to stress and do not necessarily need to be eliminated. These mechanisms serve the purpose of reducing anxiety during times of stress. While some defense mechanisms may be maladaptive, they can also help individuals cope with challenging situations. It is essential for the nurse to recognize that addressing defense mechanisms should be done sensitively, as they may be crucial for the client's emotional regulation. Encouraging the development of healthy coping skills while acknowledging the role of defense mechanisms in managing stress is a balanced approach in psychiatric care. Choice B is incorrect because completely eliminating defense mechanisms is not always feasible or beneficial. Choice C is incorrect as it oversimplifies the relationship between defense mechanisms and ego integrity. Choice D is incorrect as it misrepresents the role of defense mechanisms in ego functions.

Similar Questions