A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the nurse take?

Questions 42

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Quizlet HESI Mental Health Questions

Question 1 of 9

A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the nurse take?

Correct Answer: A

Rationale: Diarrhea, vomiting, and drowsiness in a client being treated with lithium carbonate for bipolar disorder may indicate lithium toxicity. The nurse should promptly notify the healthcare provider to ensure immediate medical intervention. The correct action is to prepare for the administration of an antidote if necessary. Holding the medication (Choice B) could delay necessary treatment. Considering the symptoms as normal side effects (Choice C) is incorrect as they suggest a potential serious issue. Notifying the healthcare provider before the next administration of the drug (Choice D) may delay urgent intervention required for lithium toxicity.

Question 2 of 9

A client with a history of substance abuse is admitted to the hospital for treatment of a new illness. Which of the following is the most important to assess upon admission?

Correct Answer: A

Rationale: Assessing the history of recent drug use is crucial when admitting a client with a history of substance abuse. Understanding recent drug use helps in managing potential withdrawal symptoms, preventing drug interactions with the new treatment, and ensuring appropriate care. Assessing current employment status (choice B) is important for social and financial support but is not as crucial as assessing recent drug use in this scenario. Family history of mental illness (choice C) and recent weight changes (choice D) are also important aspects of assessment but are not as immediate and critical as evaluating recent drug use in a client with a history of substance abuse.

Question 3 of 9

The nurse is assessing a client who has schizophrenia and is exhibiting symptoms of paranoia. Which behavior would the nurse most likely observe?

Correct Answer: B

Rationale: In clients with paranoia, they typically exhibit an intense fear of being harmed, persecuted, or targeted by others. This fear often dominates their thoughts and can significantly impact their daily functioning and interactions. Choice A, being unmotivated and withdrawn, is more indicative of negative symptoms of schizophrenia, such as avolition and social withdrawal. Choice C, displaying a blunted affect and lacking emotional response, is associated with flat affect, a symptom commonly seen in schizophrenia but not specific to paranoia. Choice D, avoiding group activities and showing decreased appetite, may be related to various symptoms or side effects, but it is not a defining characteristic of paranoia in schizophrenia.

Question 4 of 9

The healthcare professional is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued?

Correct Answer: B

Rationale: When an antipsychotic medication is discontinued, medications like Benztropine (Cogentin), which are given to reduce extrapyramidal side effects associated with traditional antipsychotic medications, should also be discontinued. Alprazolam (Xanax) is not directly related to antipsychotic medication use in this context. Magnesium (Milk of Magnesia) is a laxative and not typically indicated for bipolar disorder. Lithium (Lithotabs) is a mood stabilizer commonly used in bipolar disorder, and its discontinuation should be carefully managed under the guidance of a healthcare provider to prevent relapse of symptoms.

Question 5 of 9

A female client engages in repeated checks of door and window locks, a behavior that prevents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take?

Correct Answer: D

Rationale: Planning a list of daily activities can help the client manage her time better and reduce the impact of her compulsive behaviors. Option A is incorrect because simply asking why the client checks the locks may not address the underlying issue effectively. Option B is not relevant to the compulsive behavior of checking locks. Option C does not directly address the client's compulsive behavior but focuses on the physical attributes of the locks.

Question 6 of 9

The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (SOA)

Correct Answer: B

Rationale: B: Establishing a code with family and friends is important as it helps discreetly communicate the need for help without alerting the abuser. D: Having a bag prepared with essentials ensures the victim can swiftly leave if required. A: Purchasing a gun can escalate violence and is not a recommended safety strategy. C: Taking a self-defense course focused on protecting oneself is beneficial, but courses that involve retaliation are not recommended as they can increase risk and escalate violence.

Question 7 of 9

Narcan was administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate (Vicodin). Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?

Correct Answer: C

Rationale: Observing the client for further narcotic effects is the priority at this time. It is crucial to monitor the client closely to prevent a relapse of symptoms or potential complications from the overdose. Encouraging fluid intake, obtaining serum Vicodin levels, and determining the reason for the suicide attempt are important but are secondary to ensuring the client's immediate safety and well-being by observing for any lingering effects of the narcotic.

Question 8 of 9

The nurse on the day shift receives report about a client with depression who was found on the floor in the morning. What intervention is best for the nurse to implement?

Correct Answer: A

Rationale: Assisting the client to engage in activities is the best intervention as it can help improve mood and prevent further decline in function. Option B, monitoring appetite and sleep patterns, is important but not the most immediate intervention needed in this situation. Option C, assessing feelings about the hospital stay, is also important but addressing the client's physical safety and well-being should take precedence. Option D, explaining the frequency of staff checks, is not as effective in addressing the client's immediate needs for engagement and support.

Question 9 of 9

When preparing to administer a domestic violence screening tool to a female client, which statement should the RN provide?

Correct Answer: D

Rationale: The correct answer is D because screening all clients for domestic abuse helps normalize the process and reduces the stigma, encouraging honest responses. Choice A is not the best option as it may come off as accusatory and can deter the client from being open. Choice B, mentioning state law, may create fear or pressure, affecting the client's response. Choice C focuses on the healthcare provider's needs rather than emphasizing the client's well-being, which may not facilitate open communication.

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