The nurse administers each of the following drugs to various patients. The patient who should be most carefully assessed for fluid and electrolyte imbalance is the one receiving:

Correct Answer: A

Rationale: The correct answer is A: Lithium (Eskalith). Lithium is known to cause fluid and electrolyte imbalances by affecting sodium and water reabsorption in the kidneys. Patients on lithium therapy should be closely monitored for signs of dehydration, hyponatremia, and other electrolyte disturbances. Clozapine, Diazepam, and Amitriptyline do not typically cause significant fluid and electrolyte imbalances. Monitoring is still important, but not as critical as with lithium.

Correct Answer: C

Rationale: The correct answer is C: Acute symptom stabilization. In this situation, the main focus of care is to address the immediate threat of harm to the patient's wife by stabilizing the patient's acute symptoms. This involves ensuring the patient's safety and the safety of others through interventions such as medication management and behavioral interventions. Long-term therapy (choice A) would not be the immediate priority, as the focus is on managing the current crisis. Rehabilitative services (choice B) focus on long-term recovery and functioning, which is not the primary goal at this stage. 24-hour supervision (choice D) may be necessary as part of the care plan, but it is not the primary focus of care in this scenario.

Correct Answer: C

Rationale: The correct answer is C: Developing the therapeutic relationship. In complex somatic symptom disorder, patients often have difficulty trusting healthcare providers and may resist treatment. Developing a therapeutic relationship requires patience, empathy, and understanding. It is crucial for effective care as it allows the nurse to address the underlying psychological issues contributing to the somatic symptoms. Pain management (choice A) and anxiety relief (choice B) are important but may be more straightforward compared to building trust and rapport. Monitoring treatment (choice D) is essential but can be done effectively once a therapeutic relationship is established.

Correct Answer: A

Rationale: The correct answer is A: Risk for falls R/T right-sided weakness and sedation from risperidone. This is the priority nursing diagnosis because the client's physical aggression and right-sided weakness increase the risk of falls, which can lead to further injury. The sedative effect of risperidone can further impair the client's balance and coordination, exacerbating the risk. Addressing this risk is crucial to ensure the safety and well-being of the client. Summary of other choices: B: Activity intolerance R/T right-sided weakness - While this is a relevant concern, it is not the priority as the risk of falls takes precedence. C: Disturbed thought processes R/T acting-out behaviors - While the client's behavior may be a concern, addressing the immediate risk of falls is more critical. D: Anxiety R/T change in health status and dependence on others - While anxiety may be present, addressing the risk of falls is more urgent in this situation.

Correct Answer: A

Rationale: The correct answer is A: Lithium (Eskalith). Lithium is known to cause fluid and electrolyte imbalances by affecting sodium and water reabsorption in the kidneys. Patients on lithium therapy should be closely monitored for signs of dehydration, hyponatremia, and other electrolyte disturbances. Clozapine, Diazepam, and Amitriptyline do not typically cause significant fluid and electrolyte imbalances. Monitoring is still important, but not as critical as with lithium.

Correct Answer: C

Rationale: Rationale for Choice C (Increase the pleasure of living): Bupropion is an antidepressant that works by increasing dopamine and norepinephrine levels in the brain, which can help improve mood and overall sense of pleasure. Given Garrett's emotional flatness and lack of warmth in his relationships, bupropion can potentially enhance his ability to experience pleasure in life and improve his overall quality of life. Summary of Incorrect Choices: A: Improving flat emotions is a potential benefit of bupropion, but the primary goal is not just to improve emotions, but to increase the pleasure of living. B: While bupropion can sometimes help with sleep disturbances, the main reason for prescribing it in Garrett's case is to address his emotional flatness and lack of enjoyment in life. D: Bupropion is not specifically indicated to prepare someone for group therapy; its main purpose in this scenario is to improve Garrett's overall sense of pleasure and enjoyment in life.

Correct Answer: B

Rationale: The correct answer is B because the female reporting still hearing her daughter's pleas for help is exhibiting symptoms characteristic of acute stress reaction, a common response to traumatic events like a major fire. This symptom indicates a re-experiencing of the traumatic event, known as intrusion, which is a key feature of acute stress reactions. This can include vivid memories, flashbacks, or hearing sounds related to the traumatic event. Choices A, C, and D do not align with acute stress reactions. A male with mood swings between mania and depression (Choice A) is more likely experiencing bipolar disorder. A male repeating 'I don't understand what's going on?' (Choice C) may indicate confusion or disorientation rather than acute stress reaction. A female rocking her young son and repeating 'it will be okay' (Choice D) may be demonstrating a coping mechanism rather than a symptom of acute stress reaction.

Correct Answer: A

Rationale: The correct answer is A because it promotes cognitive-behavioral techniques to manage anger effectively. By helping the patient identify triggering thoughts, evaluate their validity, and replace them with reality-based thinking, nurses can assist in changing the patient's response to anger. This intervention encourages self-awareness and empowers the patient to develop healthier coping mechanisms. Choice B is incorrect as it promotes punitive measures, which can escalate aggression and undermine trust between the patient and healthcare provider. Choice C is incorrect as aversive conditioning methods like popping a rubber band on the wrist are not evidence-based and can be harmful. Choice D is incorrect as medication should not be the first-line intervention for managing anger without violence.

Correct Answer: B

Rationale: The correct answer is B. By informing the student's instructor and the client's primary nurse, the nursing student upholds the ethical principle of veracity, which is being truthful and honest. This action ensures that the correct dosage of medication is administered to the client, preventing potential harm. Documenting the situation is essential for accurate record-keeping and accountability. Choice A is incorrect because keeping the information confidential would go against the ethical principle of veracity and could potentially harm the client. Choice C is incorrect as the decision about actions should involve healthcare professionals to ensure the client's safety and well-being, not solely the client. Choice D is incorrect because even if the client was not harmed immediately, incorrect medication dosages could still have long-term consequences, making it crucial to report the incident for proper evaluation and prevention.