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Questions 176

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Question 1 of 5

The clinic nurse evaluates a client who was prescribed lithium therapy a month ago for bipolar disorder. Which client statement would cause the most concern?

Correct Answer: C

Rationale: Stomach flu (
C) can cause dehydration, increasing lithium toxicity risk, requiring immediate concern. Naps (
A), weight gain (
B), and dry mouth (
D) are less urgent side effects.

Question 2 of 5

Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? Select all that apply.

Correct Answer: A, C, D

Rationale: Dimming lights (
A), opening blinds in the morning (
C), and scheduling activities during the day (
D) promote circadian rhythms and rest. Leaving the TV on (
B) may disrupt sleep, and turning off alarms (E) compromises safety.

Question 3 of 5

The nurse is reviewing laboratory test results for an 80-year-old client who has a methicillin-resistant Staphylococcus aureus infection and is receiving vancomycin. Which of the following test results would require immediate follow-up?

Correct Answer: A

Rationale: Elevated BUN (
A) may indicate nephrotoxicity, a serious side effect of vancomycin requiring immediate follow-up. Decreased iron (
B) or triglycerides (
C) are not directly related to vancomycin toxicity. Elevated glucose (
D) may need monitoring but is less urgent.

Question 4 of 5

A client who received complete thickness burns at 7:30 a.m. was rushed to the emergency room where IV therapy with Lactated Ringer's was begun. He is to receive $8,000 \mathrm{~mL}$ of solution in 24 hours. According to the Parkland formula, how much solution should he receive by 11:30 p.m.?

Correct Answer: C

Rationale: The Parkland formula states half the total fluid (4,000 mL) is given in the first 8 hours (by 3:30 p.m.), and the remaining 4,000 mL over the next 16 hours. By 11:30 p.m. (16 hours post-burn), the client should have received 6,000 mL.

Question 5 of 5

The nurse is assisting the physician with an examination of a client with Addison's disease. During the examination, the nurse will note which change in the client's integumentary system?

Correct Answer: C

Rationale: Addison's disease causes bronze pigmentation due to increased ACTH. Edema , hirsutism , and pendulous abdomen are not typical.

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