Nursing Elites

1. Tatiana has been hospitalized for an acute manic episode. On admission, the nurse suspects lithium toxicity. What assessment findings would indicate the nurse's suspicion as correct?

• A. Shortness of breath, gastrointestinal distress, chronic cough
• B. Ataxia, severe hypotension, large volume of dilute urine
• C. Gastrointestinal distress, thirst, nystagmus
• D. Electroencephalographic changes, chest pain, dizziness

Correct answer: B

Rationale: The correct answer is B. Ataxia, severe hypotension, and a large volume of dilute urine are classic signs of lithium toxicity. Ataxia refers to a lack of muscle coordination, severe hypotension indicates dangerously low blood pressure, and the large volume of dilute urine is a result of the kidneys' inability to concentrate urine properly, a common feature of lithium toxicity.

2. During an assessment, a nurse observes a client showing signs of moderate anxiety. Which symptom is not typically associated with moderate anxiety?

• A. Fidgeting
• B. Laughing inappropriately
• C. Palpitations
• D. Nail biting

Correct answer: C

Rationale: When assessing a client with moderate anxiety, the nurse should anticipate signs such as fidgeting, laughing inappropriately, and nail biting. These behaviors are common manifestations of increased stress levels. Palpitations, on the other hand, are more commonly associated with severe anxiety or panic attacks. Other symptoms of severe anxiety may include restlessness, difficulty concentrating, muscle tension, and sleep disturbances.

3. A healthcare provider is assessing a client with suspected bipolar disorder. Which of the following findings should the healthcare provider expect? Select one that does not apply.

• A. Periods of elevated mood
• B. Decreased need for sleep
• C. Flight of ideas
• D. Anhedonia

Correct answer: D

Rationale: Findings in a client with bipolar disorder typically include periods of elevated mood, decreased need for sleep, and flight of ideas. Anhedonia, characterized by the inability to experience pleasure, is more commonly associated with major depressive disorder. Therefore, the healthcare provider should not expect anhedonia in a client with suspected bipolar disorder. The other choices are characteristic features of bipolar disorder, such as mania or hypomania.

4. A client with bipolar disorder is prescribed lithium. Which of the following statements by the client indicates a need for further teaching?

• A. I should maintain a consistent salt intake.
• B. I should drink 6-8 glasses of water daily.
• C. I need to have my lithium levels checked regularly.
• D. I can stop taking my medication once my mood stabilizes.

Correct answer: D

Rationale: The statement "I can stop taking my medication once my mood stabilizes" indicates a need for further teaching. Clients should continue taking their medication as prescribed and have regular monitoring of lithium levels.

5. A new psychiatric nurse states, 'This client's use of defense mechanisms should be eliminated.' Which is a correct evaluation of this nurse's statement?

• 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 help individuals reduce anxiety during times of stress. It is crucial for the nurse to understand that defense mechanisms serve a purpose and can be a normal part of coping. However, if defense mechanisms significantly hinder the client's ability to develop healthy coping skills, they should be addressed and explored. Eliminating defense mechanisms entirely without considering the individual's overall coping strategies can be counterproductive and may lead to increased distress for the client. Choice B is incorrect because not all defense mechanisms are maladaptive; some can be adaptive and helpful. Choice C is incorrect because labeling individuals as having weak ego integrity based on their use of defense mechanisms is stigmatizing and oversimplified. Choice D is incorrect because fostering and encouraging defense mechanisms without differentiation can lead to maladaptive behaviors and reliance on these mechanisms instead of healthier coping strategies.

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