The RN is admitting a male client who takes lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately?

Correct Answer: D

Rationale: The correct answer is D: Nausea and vomiting. Lithium is known to cause gastrointestinal side effects, such as nausea and vomiting, which can potentially indicate toxicity. The RN should report this immediately to the healthcare provider as it could be a sign of lithium toxicity, which can be life-threatening. A: Short-term memory loss is a common side effect of lithium, but it is not an urgent concern that requires immediate reporting. B: Five-pound weight gain is a common side effect of lithium, but it is not an urgent concern that requires immediate reporting. C: Decreased affect is a common side effect of lithium, but it is not an urgent concern that requires immediate reporting.

Correct Answer: B

Rationale: Rationale: Option B is the correct choice because it adheres to a tyramine-restricted diet. Mashed potatoes, ground beef patty, corn, green beans, and apple pie are all low in tyramine. Tyramine is found in aged, fermented, and pickled foods, as well as in certain fruits and vegetables. The other options contain foods high in tyramine: hot dogs, banana bread, caffeinated coffee (Option A); avocado, ham, chocolate cake (Option C); and smoked sausage, cheddar cheese, and yeast rolls (Option D). Therefore, Option B is the best choice for a tyramine-restricted diet.

Correct Answer: A

Rationale: The correct answer is A: Make observations. This technique is effective because it allows the nurse to show nonjudgmental acceptance and support without pressuring the patient to engage in lengthy conversations. By making observations, the nurse can acknowledge the patient's behavior without requiring a response, thus respecting the patient's need for space and limited interaction. Option B: Asking the patient direct questions may feel intrusive and overwhelming for someone with major depressive disorder who is withdrawn. Option C: Phrasing questions to require yes or no answers limits the patient's ability to express themselves fully and may not promote a sense of support and acceptance. Option D: Frequently reassuring the patient to reduce guilt feelings may come across as insincere or patronizing, and may not address the patient's need for nonjudgmental acceptance in communication.

Correct Answer: B

Rationale: The correct answer is B: Risk for suicide. The patient's belief of having cancer as punishment indicates distorted thinking and a high level of hopelessness, which increases the risk for suicide. This is a priority because it addresses the immediate safety of the patient. Powerlessness (A) may be relevant but doesn't address the imminent risk of harm. Stress overload (C) is not as critical as suicide risk in this scenario. Spiritual distress (D) may be present but doesn't address the immediate safety concern of potential suicide.

Correct Answer: C

Rationale: Rationale: C is correct because it addresses the patient's concern by explaining the time lag before antidepressants relieve symptoms. It educates the patient on the delayed onset of action for antidepressants, setting realistic expectations. A: Increasing the dose without waiting for the full effect can lead to adverse effects. B: Reassurance without providing education may not address the patient's misunderstanding. D: Critical assessment for improvement is important, but educating the patient about the medication is the immediate priority.