NCLEX-RN
Psychiatric Mental Health Nursing NCLEX RN Questions Part 2 Questions
Extract:
The nurse in the behavioral health clinic is caring for a 48-year-old male client.
• Diagnostic Results
Diagnostic, Result ,Reference Range
Calcium, 10.5 mg/di (2.75mmol/I), 9.0-10.5 mg/dL (2.25-2.75 mmol/L)
Chloride, 99 mEq/1 (99 mmol/l), 98 to 106 mEq/L (98 to 106 mmol/l)
Creatinine, 0.9 mg/dI (79.6mcmol/L), 0.6 to 1.2 mg/di (53-106 mcmol/L)
Potassium, 3.8 mEq/1 (3.8, mmol/D), 3.5-5.0 mEq/L (3.5-5.0 mmol/L)
Sodium,137 mEq/1 (137mmol/l), 135 to 145 mEq/1 (135 to 145 mmol/I)
Blood urea nitrogen,12 mg/di (4.2mmol/I), 10-20 mg/dL (3.6-7.1 mmol/L)
Fasting glucose ,202 mg/dL (11.2mmol/L), 70-110 mg/dL (4-6 mmol/L)
White blood cell, 11,000/mm3 (11 × 109 /L), 5,000-10,000/mm 3 (5-10 × 109 /L)
Hemoglobin (Hgb), 15 g/dL (150 g/L), Male: 14-18 g/dL (140-180 g/L) Female: 12-16 g/dL (120-160 g/L)
Hematocrit (Hct), 45% (0.47), Male: 42%-52% (0.42-0.52) Female: 37%-47% (0.37-0.47)
Lithium level, 0.4 mEg/L , 0.6-1.2 mEg/L
• Nurses’ Notes
1230: Client presents for a follow-up appointment. He reports 100% adherence with prescribed ziprasidone. Two weeks ago, he was prescribed lithium, for which he reports a mild thirst. This thirst is causing him to go to the bathroom more frequently overnight. He reports that he recently got a second job to save for a vacation. On assessment, the client is alert and completely oriented. He had a logical thought process. Lung sounds clear bilaterally, and peripheral pulses were 2+. Skin is warm, dry, and normal for ethnicity. Rapid eye blinking and persistent chewing motions in his mouth despite not eating any food or gum. He reports that this started two weeks ago. Current weight is 128 kg (282 pounds). Current BMI is 26kg/m2. Previous weight one month ago was 126 kg (277 pounds). The most recent hospitalization was one month ago for a manic episode. Laboratory data reviewed.
Question 1 of 5
The nurse is reviewing the initial intake information. Which of the following assessment findings requires immediate follow-up? Select all that apply.
Correct Answer: B,C,D,E,F
Rationale: The client’s eye blinking and chewing motion indicates extrapyramidal symptoms (EPS), specifically tardive dyskinesia, a potential adverse effect of ziprasidone (an atypical antipsychotic). These movements are involuntary, persistent, and can become irreversible. Prompt evaluation is needed to consider a change in medication or dosage.
The client’s plasma glucose level is significantly elevated and in the diabetic range (≥126 mg/dL fasting). Atypical antipsychotics like ziprasidone can contribute to glucose dysregulation. This finding requires immediate follow-up to assess for diabetes or worsening glucose control.
The client’s lithium level is subtherapeutic; the therapeutic range is 0.6–1.2 mEq/L. While not immediately dangerous, it indicates that lithium is not yet at an effective dose, putting the client at risk for recurrence of mania, especially with the recent hospitalization for a manic episode.
The client’s body mass index (BMI) requires follow-up. While this normally not require immediate follow-up, this combined with the client’s significantly elevated plasma glucose level suggests metabolic syndrome.
The other findings, including the slightly elevated white blood cell count, normal hemoglobin and hematocrit, and reports of mild thirst, do not require urgent follow-up at this time. Lithium is known to cause a client to experience a mild thirst. Additionally, leukocytosis is common with lithium. These findings can be monitored over time unless they worsen or are accompanied by other concerning symptoms.
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