NCLEX-RN
Mental Health RN NCLEX Questions 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 performs the Abnormal Involuntary Movement Scale and determines that the client is experiencing tardive dyskinesia. For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client
| Potential interventions | Indicated | Not indicated |
|---|---|---|
| obtain an order to discontinue ziprasidone | ||
| obtain an order for a serum hemoglobin A1C | ||
| inquire further about the client’s lithium adherence | ||
| obtain a prescription for benztropine | ||
| obtain an order to discontinue lithium |
Correct Answer:
Rationale: Discontinuation of ziprasidone is indicated because the client is exhibiting signs of tardive dyskinesia, which is a serious and potentially irreversible side effect of long-term antipsychotic use. The most effective initial approach to managing tardive dyskinesia is to stop the offending agent, especially when symptoms are newly emerging.
Ordering a hemoglobin A1C is appropriate given that the client has a fasting glucose of 202 mg/dL (11.2 mmol/L), which is in the diabetic range. A hemoglobin A1C would provide information on the average blood glucose over the past two to three months, helping to confirm a diagnosis of diabetes mellitus (type two) and guide long-term treatment planning.
It is also important to inquire further about the client’s adherence to lithium. The serum lithium level is currently 0.4 mEq/L, which is subtherapeutic. Understanding whether the client is taking the medication as prescribed or missing doses will help determine if a dose adjustment or adherence support is needed to ensure effective mood stabilization.
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