a man is prescribed lithium to treat bipolar disorder the nurse is most concerned about lithium toxicity when he notices which of these assessment fin a man is prescribed lithium to treat bipolar disorder the nurse is most concerned about lithium toxicity when he notices which of these assessment fin
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NCLEX RN Exam Questions

1. A man is prescribed lithium to treat bipolar disorder. The nurse is most concerned about lithium toxicity when he notices which of these assessment findings?

Correct answer: The patient states he has been having diarrhea every day

Rationale: The correct answer is when the patient states he has been having diarrhea every day. Persistent diarrhea can lead to dehydration, which can increase the risk of lithium toxicity. The other options, such as a manic episode, severe depression, or rash and pruritus, are not directly associated with an increased risk of lithium toxicity.

2. What does preload refer to?

Correct answer: B: The volume of blood entering the right side of the heart

Rationale: Preload refers to the volume of blood that enters the right side of the heart. This volume stretches the fibers in the heart before contraction. Preload is an essential factor in determining the force of ventricular contraction. Choices A, C, and D are incorrect. Choice A is incorrect because preload is specifically related to the volume of blood entering the right side of the heart. Choices C and D are incorrect as they refer to afterload, which is the pressure that the heart must overcome to pump blood out of the ventricles into the systemic or pulmonary circulation.

3. A client asks the nurse, 'Should I tell my partner that I just found out I’m human immunodeficiency virus (HIV) positive?' Which is the nurse’s most appropriate response?

Correct answer: You are having difficulty deciding what to say.

Rationale: The most appropriate response for the nurse in this situation is to acknowledge the client's struggle in deciding what to communicate to their partner. By stating 'You are having difficulty deciding what to say,' the nurse validates the client's feelings and encourages further discussion. Option A is incorrect as it suggests withholding information unless asked, which may not align with ethical principles of honesty and transparency in relationships. Option B, while acknowledging the client's autonomy, does not provide direct support or guidance. Option D is inappropriate as it involves dishonesty by suggesting telling the partner an untruthful reason for the illness.

4. A client had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires immediate attention?

Correct answer: Client reports prickling sensation in the right hand

Rationale: A prickling sensation in the right hand is indicative of compartment syndrome, a serious condition that can lead to tissue damage and impaired circulation. Immediate attention is required to prevent complications. Capillary refill of 3 seconds, warm and normally colored skin, and slight swelling of fingers are expected findings after a closed reduction and casting. These findings do not typically indicate a critical issue and can be managed with routine monitoring.

5. While explaining an illness to a 10-year-old, what should the nurse keep in mind about the cognitive development at this age?

Correct answer: They are able to think logically in organizing facts

Rationale: At the age of 10, children are in the concrete operations stage according to Piaget. They are capable of mature thought when allowed to manipulate and organize objects. This means they can think logically, organize facts, and understand cause-and-effect relationships. Choices A, C, and D are incorrect. While simple associations of ideas may occur, the key cognitive ability at this stage is the capacity for logical thought and organization of information. Interpretation of events from their own perspective is more characteristic of younger children, and conclusions based on previous experiences are more aligned with older children or adults.

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