Josefina is to be discharged on a regimen of lithium carbonate. In the teaching plan for discharge the nurse should include:
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Solution
Encouraging the client to have blood levels checked as ordered.
Option D: Blood levels must be checked monthly or bimonthly when the client is on maintenance therapy because there is only a small range between therapeutic and toxic levels.
Nurse Kate would expect that a client with vascular dementia would experience:
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Solution
Disturbance in recalling recent events related to cerebral hypoxia.
Option D: Cell damage seems to interfere with registering input stimuli, which affects the ability to register and recall recent events; vascular dementia is related to multiple vascular lesions of the cerebral cortex and subcortical structure.
Nurse Krina recognizes that the suicidal risk for depressed client is greatest:
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Solution
As their depression begins to improve
Option A: At this point, the client may have enough energy to plan and execute an attempt.
Jen a nursing student is anxious about the upcoming board examination but is able to study intently and does not become distracted by a roommate’s talking and loud music. The student’s ability to ignore distractions and to focus on studying demonstrates:
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Solution
Moderate-level anxiety
Option D: A moderately anxious person can ignore peripheral events and focuses on central concerns.
Miranda a psychiatric client is to be discharged with orders for haloperidol (Haldol) therapy. When developing a teaching plan for discharge, the nurse should include cautioning the client against:
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Solution
Staying in the sun
Option B: Haldol causes photosensitivity. Severe sunburn can occur on exposure to the sun.
The outcome that is unrelated to a crisis state is:
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Solution
A higher level of anxiety continuing for more than 3 months.
Option D: This is not an expected outcome of a crisis because by definition a crisis would be resolved in 6 weeks.
A dying male client gradually moves toward resolution of feelings regarding impending death. Basing care on the theory of Kubler-Ross, Nurse Trish plans to use nonverbal interventions when assessment reveals that the client is in the:
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Solution
Acceptance stage
Option D: Communication and intervention during this stage are mainly nonverbal, as when the client gestures to hold the nurse’s hand.
The nurse is aware that the side effect of electroconvulsive therapy that a client may experience:
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Solution
Confusion for a time after treatment
Option C: The electrical energy passing through the cerebral cortex during ECT results in a temporary state of confusion after treatment.
Nicolas is experiencing hallucinations tells the nurse, “The voices are telling me I’m no good.” The client asks if the nurse hears the voices. The most appropriate response by the nurse would be:
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Solution
“No, I do not hear your voices, but I believe you can hear them”.
Option B: The nurse, demonstrating knowledge and understanding, accepts the client’s perceptions even though they are hallucinatory.