3291 Interventions exam 3

The nurse is working with a client who has been diagnosed with depression. When performing a strength assess with the client, what is the nurse's best statement or question? "It's important that you remember that you're an exceptionally strong and capable person." "How have you dealt with feelings like this in the past?" "Do you consider yourself to be a strong person overall?" "What can the care team do to help you become a stronger person?"

"How have you dealt with feelings like this in the past?"

A client with a history of self-harm reports lethargy, loss of appetite and insomnia to the nurse. The client states that she relies heavily on sleep medications that her primary care provider prescribed. What is the nurse's priority assessment question. "Have you ever had to take sleeping pills at any other point in your life?" "Are their any strategies you've tried so that you wouldn't need sleeping pills?" "How do you feel about having to take medication to help you sleep?" "How many of the sleeping pills do you have at home right now?"

"How many of the sleeping pills do you have at home right now?"

At 1 a.m., the client with mania rushes to the nurses' station and demands that the psychiatrist come to the unit now to write an order for a pass to go home. Which response by the nurse would be the most therapeutic?

"I can't call the psychiatrist now, but you and I can talk about your request for a pass.". This response states a limit on an unreasonable request while providing the opportunity to discuss the request. Answers A, B, and D are not therapeutic.

A nurse can estimate serum osmolality at the bedside by using a formula. A patient who has a serum sodium level of 140 mEq/L would have a serum osmolality of:

280 mOsm/kg.

A client with major depression is admitted to the health facility and expresses feelings of worthlessness and abandonment by significant others. Which replies by the nurse would convey empathy? "Can you tell me what you are thinking right now?" "I can understand what is going on with you." "It sounds like this is a really difficult time for you." "Are you feeling like others have abandoned you?"

"It sounds like this is a really difficult time for you."

In a report, the nurse learns that a client with mania has not slept since admission 2 days ago. On entering the day room, the nurse finds this client dancing to loud music. The best response by the nurse would be ... "Let's go to the conference room and talk for a while." "Turn the radio down so we can hear ourselves talk." "Do you think you could sit still for a few minutes so we can talk?" "How are you ever going to get any rest if you keep that music on?" "Let's go to the conference room and talk for a while."

"Let's go to the conference room and talk for a while."

A client is readmitted to the substance abuse program for the second time in 6 months for alcohol abuse. On admission, he tells the nurse, "I am so ashamed." What should the nurse reply?

"Tell me what has happened since your last admission."

A client who is depressed begins to cry and states, "I'm just really sick of feeling this way. Nothing ever seems to go right in my life." Which would be the most appropriate response by the nurse? "Nothing ever goes right?" "Don't cry. Try to look at the positive side of things." "Hang in there. Your medication will start helping in a few days." "You are feeling really sad right now. It's a hard time." "You are feeling really sad right now. It's a hard time."

"You are feeling really sad right now. It's a hard time."

A client with bipolar disorder is receiving lithium therapy. The nurse is reviewing the client's serum plasma drug levels and determines that the client's level is therapeutic based on what? 2.0 mEq/L 1.6 mEq/L 2.6 mEq/L 1.0 mEq/L 1.0 mEq/L

1.0 mEq/L

Which of the following describes the monoamine hypothesis for the etiology of depression? Depression is caused by only one of the biogenic amines. This relates to bipolar disorders, not to depression. Depression results from a deficiency in the concentrations or in metabolic dysregulation of the monoamines. Depression is caused by sociocultural and psychological factors.

2.

A patient has no expression when conversing with the nurse. This would be documented as which type of affect? A- Flat B- Blunted C- Labile D- Inappropriate

A

A client is prescribed phenelzine (Nardil) to treat her depression. She is at a local café for lunch with a friend. Which of the following items on the menu would be least appropriate for the client to order? a) A Cobb salad with blue cheese and Roquefort salad dressing b) Medium-well steak, French fries, and broccoli c) Scrambled eggs, toast, and grape jelly d) Roast beef, mashed potatoes, and gravy

A Cobb salad with blue cheese and Roquefort salad dressing Explanation: Phenelzine is a monoamine oxidase inhibitor (MAOI). If co-administered with food or other substances containing tyramine (e.g., aged cheese, beer, red wine), MAOIs can trigger a hypertensive crisis that may be life threatening. The blue cheese is aged, and the Roquefort salad dressing contains aged cheese.

Which sleep pattern is suggestive of a manic episode? A client takes multiple short naps at varied times throughout the day and night. A client stays awake for several days and nights before "crashing" and sleeping for a long period. A client experiences day-night reversal, sleeping until late in the afternoon and going to bed near dawn. A client reports having fitful sleep that is characterized by frequent awakenings and nightmares.

A client stays awake for several days and nights before "crashing" and sleeping for a long period.

The nurse is caring for a patient receiving a tricyclic antidepressant and is monitoring for anticholinergic side effects. Anticholinergic effects include which of the following? a) Blurred vision b) Hyperactive bowel sounds c) Urinary incontinence d) Moist skin

A.

A depressed patient states, "I think my family would be better off without me. They don't need to worry." The most appropriate response by the nurse would be:

Are you planning to commit suicide?"

A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of solution?

Acidic

A loss of pleasure or interest in the patient diagnosed with depression would be documented as which of the following? A- Discouragement B- Anhedonia C- Hopelessness D- Flat Affect

B

Carrie, age 20, was admitted to your unit following a suicide attempt. She is disheveled, disorganized, and dehydrated. The priority for her care during the first 24 hours of her admission is a) assisting Carrie with her activities of daily living, including a shower and clean clothing. b) assessing Carrie's current suicidal ideation and putting her on suicide precautions. c) rehydrating Carrie by forcing fluids. d) assessing Carrie's recent suicide attempt and identifying factors that may have contributed to it.

B

A group of nursing students are studying for a test over acid-base imbalance. One student asks another what the major chemical regulator of plasma pH is. What should the second student respond?

Bicarbonate-carbonic acid buffer system - The major chemical regulator of plasma pH is the bicarbonate-carbonic acid buffer system.

A client with bipolar disorder has been ordered a medication that is classified as an anticonvulsant. Which drug does the nurse know falls within this class of medications? Mannitol Carbamazepine Lithium Methyldopa Carbamazepine

Carbamazepine

Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism?

Chest Pain - Manifestations of air embolism include dyspnea and cyanosis; hypotension; weak, rapid pulse; loss of consciousness; and chest, shoulder, and low back pain. Jaundice is not associated with air embolism.

The nurse is planning the inpatient care of a client who has been admitted with major depression. The client's plan of care includes regular exercise, but the client is reluctant to participate due to a lack of energy and motivation. What is the nurse's best action? Describe the benefits of exercise to the client and state that privileges will be lost if the client does not participate Arrange for the client to exercise approximately 1 hour after antidepressant administration Teach the client isometric exercises that the client can complete while in bed Collaborate with the client to choose a manageable amount of exercise and acknowledge the client's subsequent effort

Collaborate with the client to choose a manageable amount of exercise and acknowledge the client's subsequent effort

The nurse is planning the inpatient care of a client who has been admitted with major depression. The client's plan of care includes regular exercise, but the client is reluctant to participate due to a lack of energy and motivation. What is the nurse's best action? Describe the benefits of exercise to the client and state that privileges will be lost if the client does not participate Arrange for the client to exercise approximately 1 hour after antidepressant administration Teach the client isometric exercises that the client can complete while in bed Collaborate with the client to choose a manageable amount of exercise and acknowledge the client's subsequent effort Collaborate with the client to choose a manageable amount of exercise and acknowledge the client's subsequent effort

Collaborate with the client to choose a manageable amount of exercise and acknowledge the client's subsequent effort

A client with major depression is scheduled to receive electroconvulsive therapy. The nurse understands that this treatment is typically used in which situation? The client is tolerating the initial drug therapy. Suicidality is of little concern. The client is experiencing catatonia. The level of depression is mild to moderate

The client is experiencing catatonia.

Which drug reverses opioid toxicity?

Naloxone (Narcan)

A father of four small children lost his wife in an automobile accident 3 months ago and is admitted to the hospital with severe depression. Since his wife's death, his mood has been somber; until now, he has refused treatment. For what is this patient at high risk? a) Schizophrenia b) Dysthymic disorder c) Bipolar disorder d) Suicide

D

Research has shown that risk of suicide increases within which timeframe for initiation of antidepressant therapy? a) 35 days b) 42 days c) 28 days d) 14 days

D

Which of the following antidepressant medications is classified as a selective serotonin reuptake inhibitor (SSRI)? a) Tranylcypromine (Parnate) b) Phenelzine (Nardil) c) Isocarboxazid (Marplan) d) Fluoxetine (Prozac)

D

Which of the following electrolytes is a major cation in body fluid? a) Phosphate b) Chloride c) Bicarbonate d) Potassium

D

A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse became alarmed when the client demonstrated confusion and elevated temperature, and reported "dry mouth." The nurse suspects the client is experiencing which condition?

Dehydration

Which of the following statements regarding depression and gender is correct?

Depressive disorders are more common in women than men. Depressive disorders are more prevalent in women than in men. Genetics, sociocultural factors, hormones, and other elements may account for this disparity.

Which disorder is characterized by at least 2 years of depressed mood for more days than not with some additional, less severe symptoms that do not meet the criteria for a major depressive episode? a) Dysthymic disorder b) Seasonal affective disorder c) Cyclothymic disorder d) Hypomania

Dysthymic disorder Explanation: Dysthymic disorder is characterized by at least 2 years of depressed mood for more days than not with some additional, less severe symptoms that do not meet the criteria for a major depressive episode. Cyclothymic disorder is characterized by 2 years of numerous periods of hypomanic symptoms that do not meet the criteria for bipolar disorder. Seasonal affective disorder occurs in the winter or spring. Hypomania is a period of abnormally and persistently elevated, expansive, or irritable mood lasting 4 days.

A client has been taking a tricyclic antidepressant (TCA) for several months and is now reporting urinary hesitation. What is the nurse's best action? Encourage the client to use a low dose of an over the counter diuretic Encourage the client to drink low-pH beverages Encourage the client to increase fluid intake Ask the primary care provider to prescribe a diuretic

Encourage the client to increase fluid intake

A client has been taking a tricyclic antidepressant (TCA) for several months and is now reporting urinary hesitation. What is the nurse's best action? Encourage the client to use a low dose of an over the counter diuretic Encourage the client to drink low-pH beverages Encourage the client to increase fluid intake Ask the primary care provider to prescribe a diuretic Encourage the client to increase fluid intake

Encourage the client to increase fluid intake

A client who has experienced the recent loss of an infant child and recent immigration to the United States is admitted to the inpatient psychiatric unit with severe symptoms of depression. The client has expressed thoughts of suicide. Which is the nurse's priority intervention for this client?

Ensuring that the client is not permitted to use anything that would be potentially dangerous.

On admission to the psychiatric unit, a client is dressed in a red leotard and exercise bra, with an assortment of chains and brightly colored scarves on the client's head, waist, wrists, and ankles. The client's first words to the nurse are, "I'll punch you, munch you, crunch you," as the client dances into the room, shadow boxing. The client shakes the nurse's hand and says cheerfully, "We need to become better acquainted. I have the world's greatest intellect, and you are probably an intellectual midget." How can the nurse document the client's mood? Anxious and unpredictable. Belligerent and blunted. Suspicious and paranoid. Expansive and grandiose.

Expansive and grandiose.

A client has been on lithium for 3 weeks now. The client approaches the nurse, saying, "I feel like I'm going to throw up, and I can't even hold this cup of coffee straight. Why can't I do the crossword puzzle? I usually can do them in about 5 minutes." What is the appropriate nursing intervention at this time? Further assess the client's symptoms, call the physician, hold the client's next dose of lithium, and have a blood level drawn because the client is showing symptoms of toxicity.

Further assess the client's symptoms, call the physician, hold the client's next dose of lithium, and have a blood level drawn because the client is showing symptoms of toxicity.

A client is admitted to the emergency department after using MDMA (Ecstasy). The nurse identifies this drug as which of the following? Stimulant Hallucinogen Sedative Opioid

Hallucinogen

A nurse is caring for a client who uses phencyclidine (PCP). PCP is classified as which type of substance?

Hallucinogen

Which meal would the nurse provide to best meet the nutritional needs of a client who is manic? Fried chicken, mashed potatoes, milk Spaghetti, garlic bread, salad, tea Peanut butter sandwich, chips, cola Ham sandwich, cheese slices, milk Ham sandwich, cheese slices, milk {Finger foods, or things clients can eat while moving around, are the best options to improve nutrition. Such foods should be as high in calories and protein as possible. Sandwiches and cheese are finger foods and are calorie-dense. Chips and cola are not nutritious, even though they are high in calories}

Ham sandwich, cheese slices, milk {Finger foods, or things clients can eat while moving around, are the best options to improve nutrition. Such foods should be as high in calories and protein as possible. Sandwiches and cheese are finger foods and are calorie-dense. Chips and cola are not nutritious, even though they are high in calories}

The nurse in an outpatient rehabilitation program is speaking with a group of clients who have recently recovered from alcohol abuse. Which issue should the nurse raise before the clients leave for the day?

Help them to identify appropriate diversional activities.

Which behavior is the priority concern as the nurse begins a care plan for a client in the manic phase of bipolar disorder? Grandiose thinking and poor concentration Bizarre, colorful, inappropriate dress Insulting, provocative behavior directed at staff Hyperactivity, dismissing meals, and sleep disturbance Hyperactivity, dismissing meals, and sleep disturbance

Hyperactivity, dismissing meals, and sleep disturbance

Electroconvulsive therapy (ECT) has been shown to be an effective treatment for people with severe depression. However, ECT is contraindicated in which of the following disease processes? Anxiety disorder Diabetes Increased intracranial pressure Hypertension Increased intracranial pressure A client with major depression is admitted to the health facility and expresses feelings of worthlessness and abandonment by significant others. Which replies by the nurse would convey empathy? "Can you tell me what you are thinking right now?" "I can understand what is going on with you." "It sounds like this is a really difficult time for you." "Are you feeling like others have abandoned you?"

Increased intracranial pressure

Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg?

Instruct the client to breathe into a paper bag. - The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag. Administering a decongestant, offering fluids frequently, and administering supplemental oxygen wouldn't raise the lowered PaCO2 level.

When discussing methadone treatment with a client, the nurse should include what?

It decreases the severity of heroin withdrawal symptoms.

A 56-year-old client who suffers from seasonal affective disorder is being assessed by the nurse in an outpatient mental health clinic. The nurse is aware which treatment is the most effective type of treatment for this condition? Electroconvulsive therapy Antidepressant therapy Psychotherapy Light therapy

Light therapy

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

Light-headedness or paresthesia - The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.

A client with bipolar disorder is prescribed divalproex sodium as part of the treatment plan. Before administering the medication, which tests should be done? Select all that apply. Urinalysis Liver function tests Blood glucose concentration Complete blood count Platelet count

Liver function tests Complete blood count Platelet count

A client has been diagnosed with major depression. The client reports that the client often wakes up during the night and has trouble returning to sleep. The nurse interprets this finding as suggesting what? Initial insomnia Terminal insomnia Hypersomnia Middle insomnia

Middle insomnia

Which medication classification is considered first-line drug therapy for bipolar disorder?

Mood stabilizers

A group of nursing students is reviewing information about nutritional supplementation used during alcohol detoxification. The students demonstrate the need for additional review when they identify which of the following as being used? Folic acid Magnesium sulfate Naloxone Thiamine

Naloxone *Naloxone (Narcan), an opioid antagonist, is given to reverse the respiratory depression, sedation, and hypertension for opioid intoxication. Multivitamins and adequate nutrition are essential for clients who are withdrawing from alcohol. Because malnutrition is common, other vitamin replacement may be necessary for certain individuals. Thiamine (vitamin B1) is initiated during detoxification, given to decrease ataxia and other symptoms of deficiency. It is usually given orally, 100 mg four times daily, but can be given intramuscularly or by intravenous infusion with glucose. Folic acid deficiency is corrected with administration of 1.0 mg orally four times daily. Magnesium deficiency also is found in those with long-term alcohol dependence. Magnesium sulfate, which enhances the body's response to thiamine and reduces seizures, is given prophylactically for clients with histories of withdrawal seizures.

A client with mania is in the dining room at lunchtime and is observed taking food from other clients' trays. The nurse's intervention should be based on which rationale? The client's behavior is not an imminent threat to anyone's physical safety. The client needs food and fluids in any way possible. Other clients need to be protected from the intrusive behavior. As soon as lunch is over, the client will calm down.

Other clients need to be protected from the intrusive behavior.

A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to the client's feelings of sadness and hopelessness, the nurse would expect to assess what? Decreased complaints of pain Psychomotor retardation Increased energy level Increased focus

Psychomotor retardation

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate?

Respiratory alkalosis - A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys' bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.

A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??') of 26 mEq/L. What disorder is indicated by these findings?

Respiratory alkalosis - Respiratory alkalosis results from alveolar hyperventilation. It's marked by a decrease in PaCO2 to less than 35 mm Hg and an increase in blood pH over 7.45. Metabolic acidosis is marked by a decrease in HCO3? to less than 22 mEq/L, and a decrease in blood pH to less than 7.35. In respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg. In metabolic alkalosis, the HCO3? is greater than 26 mEq/L and the pH is greater than 7.45.

A nurse is caring for a client diagnosed with bipolar disorder. The client is experiencing a manic episode. The nurse would be especially alert for signs indicating what? Sleep disruption Weight loss Self-injury Dehydration

Self-injury

A client who is taking paroxetine reports to the nurse that the client has been nauseated since beginning the medication. Which action is indicated initially? Tell the client to contact the physician for a change in medication. Reassure the client that this is an expected side effect that will improve with time. Suggest that the client take the medication with food. Instruct the client to stop the medication for a few days to see if the nausea goes away.

Suggest that the client take the medication with food.

A client who is taking paroxetine reports to the nurse that the client has been nauseated since beginning the medication. Which action is indicated initially? Tell the client to contact the physician for a change in medication. Reassure the client that this is an expected side effect that will improve with time. Suggest that the client take the medication with food. Instruct the client to stop the medication for a few days to see if the nausea goes away. Suggest that the client take the medication with food.

Suggest that the client take the medication with food.

The client has been diagnosed with severe depression. During the assessment of the client, the nurse is aware of which primary consideration with clients taking antidepressants? Suicide Increased sleep Decreased mobility Emotional changes

Suicide

A client who has been discharged home on citalopram calls the nurse reporting that the medication causes the client to feel too drowsy. The nurse should make which suggestion? Skip a dose if drowsiness is excessive. Take the medication at night. Be patient while this early side effect subsides. Make an appointment to change to a different medication.

Take the medication at night.

A concerned family member tells the nurse, "I am concerned about my sibling. My sibling has been acting very different lately." Knowing the family has a history of bipolar disorder, the nurse inquires further about this. Which behavior during the past week might indicate that the sibling has bipolar disorder? Intense focus Taking unnecessary risks Sleeping more Showing low self-esteem

Taking unnecessary risks

A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis?

The client had a liver transplant 2 years ago.

Which outcome would be appropriate to determine an early favorable response to antidepressant medication? The client will demonstrate assertive communication skills. The client will describe signs and symptoms of major depression. The client will make plans to attend one community social activity a week. The client will establish a balance of rest, sleep, and activity.

The client will establish a balance of rest, sleep, and activity.

Which of the following would a nurse be least likely to include when instituting behavioral therapy for a client with depression?

Thought stopping

Treatment of FVE involves dietary restriction of sodium. Which of the following food choices would be part of a low-sodium diet, mild restriction (2 to 3 g/day)?

Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad

A nurse is conducting a class for a group of high school students about marijuana use and abuse. The nurse determines that the class needs further discussion when they state which of the following?

Use of marijuana does not lead to addiction.

A client is admitted to the emergency department for intoxication with alcohol. The client has an unsteady gait, myopathy, and neuropathy and cannot remember past or recent events. When treated with thiamine, the client's symptoms greatly improve. Which condition was the client likely experiencing?

Wernicke-Korsakoff syndrome

Before a client became depressed, she was an active, involved mother with her three children, often attending their school functions and serving as a volunteer. She is hospitalized for major depressive episode and now reveals that she feels like an unnecessary burden on her family. Which of the following nursing diagnoses is most appropriate? a) Disturbance of self-concept related to feelings of worthlessness b) Anger related to marital disagreements c) Apathy related to fatigue and sleeplessness d) Anxiety related to side effects of medication

a

Susan was abandoned by her parents at age 3, resulting in her perception of the world as a hostile place and the subsequent development of rage against men. This statement is an example of a) a biophysiological explanation for Susan's depressive disorder. b) a psychodynamic interpretation of Susan's major depressive disorder. c) why Susan has become lesbian at the age of 23. d) a feminist viewpoint of depression.

a psychodynamic interpretation of Susan's major depressive disorder. Explanation: Psychodynamic theories postulate that clients with depression have unexpressed and unconscious anger about feeling helpless or dependent on others. Such anger begins in childhood when basic developmental needs are not met. They cannot express this anger toward the person or people on whom they feel dependent, so their anger turns inward.

Which of the following is the most common cause of symptomatic hypomagnesemia? a) Alcoholism b) Sedentary lifestyle c) IV drug use d) Burns

a) Alcoholism

Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate? a) Limit sodium and water intake. b) Assess for dehydration. c) Teach client behaviors that decrease urination. d) Give medications that promote fluid retention.

a) Limit sodium and water intake.

The spouse of a client with bipolar disorder calls the nurse expressing distress about recent spending patterns of the client. The nurse suggests the spouse implement the limit-setting skills the spouse has learned in family therapy. In this instance, the nurse's action would be considered ... inappropriate; the client has the legal right to spend personal money. inappropriate; the nurse should not give advice to the spouse. appropriate; the spouse needs support in setting boundaries. appropriate; the spouse is responsible for the client's actions since the client has a mental illness. appropriate; the spouse needs support in setting boundaries.

appropriate; the spouse needs support in setting boundaries.

A client is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this client, the nurse's priority should be to assess her: a) bowel sounds. b) electrocardiogram (ECG) results. c) respiratory rate. d) neuromuscular function.

b

A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance? a) Hyperkalemia b) Hypercalcemia c) Hypocalcemia d) Hypokalemia

b

The nurse is caring for a patient with a serum sodium level of 113 mEq/L. The nurse should monitor the patient for the development of which of the following? a) Nausea b) Confusion c) Hallucinations d) Headache

b

Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality? a) Potassium b) Magnesium c) Sodium d) Calcium

c

Which of the following are the insensible mechanisms of fluid loss? a) Nausea b) Bowel elimination c) Urination d) Breathing

d

Which of the following electrolytes is a major cation in body fluid? a) Chloride b) Bicarbonate c) Phosphate d) Potassium

d

Which of the following is a correct route of administration for potassium? a) IV (intravenous) push b) Subcutaneous c) Intramuscular d) Oral

d

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result? a) Serum creatinine level of 0.4 mg/dl b) Hematocrit of 52% c) Serum blood urea nitrogen (BUN) level of 8.6 mg/dl d) Serum sodium level of 124 mEq/L

d) Serum sodium level of 124 mEq/L

What is the priority nursing diagnosis for a depressed client exhibiting signs of acute mania that include agitation, insomnia, increased physical activity, and anorexia? risk for injury insomnia noncompliance chronic low self-esteem

risk for injury

What is the priority nursing diagnosis for a depressed client exhibiting signs of acute mania that include agitation, insomnia, increased physical activity, and anorexia? risk for injury insomnia noncompliance chronic low self-esteem risk for injury

risk for injury