Nursing Elites

1. A male client who has been on lithium therapy for 5 years is experiencing frequent urination and increased thirst. What should the nurse's next action be?

• A. Instruct the client to increase fluid intake.
• B. Assess for signs of lithium toxicity.
• C. Suggest the client reduce salt intake.
• D. Notify the healthcare provider immediately.

Correct answer: B

Rationale: Frequent urination and increased thirst can be signs of lithium toxicity, which can lead to serious complications if not addressed promptly. Assessing for signs of lithium toxicity is crucial to determine the client's condition and prevent further harm. Instructing the client to increase fluid intake (Choice A) may worsen the situation by exacerbating lithium toxicity. Suggesting the client reduce salt intake (Choice C) is not the priority when signs of toxicity are present. Notifying the healthcare provider immediately (Choice D) is important, but the initial action should be to assess the client for signs of lithium toxicity to provide immediate care.

2. A client with bipolar disorder is being discharged with a prescription for lithium. What is the most important instruction the nurse should provide?

• A. Avoid foods high in sodium.
• B. Drink plenty of fluids, especially during hot weather.
• C. Take your medication with food.
• D. Monitor your blood pressure regularly.

Correct answer: B

Rationale: The correct answer is to instruct the client to drink plenty of fluids, especially during hot weather. Maintaining adequate hydration is crucial for clients taking lithium as dehydration can lead to lithium toxicity. Choice A is incorrect because while it is important to monitor sodium intake, staying hydrated is more critical. Choice C is incorrect as lithium is usually recommended to be taken with food to reduce stomach upset. Choice D is also important but not the most crucial instruction compared to ensuring proper hydration.

3. The LPN/LVN is caring for a client who was recently diagnosed with a mental illness. The client asks, 'Will I be able to live a normal life?' What is the best response for the nurse to provide?

• A. Yes, you will be able to live a normal life.
• B. Many people with mental illness lead full and productive lives.
• C. It will depend on your treatment and the choices you make.
• D. There is no normal; everyone is unique in their own way.

Correct answer: C

Rationale: The best response for the nurse is to provide the client with hope while acknowledging the importance of their treatment and choices. Choice C addresses the client's concern by highlighting the impact of their treatment and personal choices on their future. It encourages personal responsibility and active participation in their recovery. Choices A and B may sound reassuring, but they do not empower the client to take an active role in their well-being. Choice D, while promoting individuality, does not directly address the client's question about living a normal life after a mental illness diagnosis.

4. A client with a history of substance abuse is admitted to the hospital for detoxification. What is the most important intervention for the LPN/LVN to implement?

• A. Monitor the client for signs of withdrawal.
• B. Encourage the client to express feelings about substance use.
• C. Provide the client with information about support groups.
• D. Administer prescribed medications to manage withdrawal symptoms.

Correct answer: D

Rationale: Administering prescribed medications to manage withdrawal symptoms is the priority intervention for a client undergoing detoxification. This intervention aims to prevent severe complications that may arise during the detox process. Monitoring for signs of withdrawal (choice A) is important but providing immediate medical management through medications takes precedence to ensure the client's safety. Encouraging the client to express feelings (choice B) and providing information about support groups (choice C) are essential aspects of care but are not as urgent as administering medications to manage withdrawal symptoms.

5. A client with schizophrenia is being treated with risperidone (Risperdal). The nurse notices that the client has a shuffling gait and tremors. What is the nurse's priority action?

• A. Administer a PRN dose of an anticholinergic medication.
• B. Document the findings and continue to monitor the client.
• C. Assess the client's blood glucose level.
• D. Notify the healthcare provider immediately.

Correct answer: A

Rationale: A shuffling gait and tremors may indicate extrapyramidal side effects (EPS) from risperidone. The nurse's priority action should be to administer an anticholinergic medication as it can help alleviate these symptoms associated with EPS. Documenting the findings and monitoring the client (Choice B) are important but addressing the immediate symptoms takes precedence. Assessing the client's blood glucose level (Choice C) is not directly related to the observed symptoms of shuffling gait and tremors. While notifying the healthcare provider (Choice D) is important, it is not the priority action when dealing with EPS symptoms.

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