questions and answers
1. A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports
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that they stopped taking lithium 2 weeks ago.The nurse should recognize which of the
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following as an expected adverse effect that might have caused the client to spot taking the
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medication?
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1. Sore throat q
2. Photophobia
3. Handtremors q
4. Constipation
ANS:Correct= 3.HandTremors
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- Fine hand tremors are an expected adverse effect of lithium and can interfere with
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performance of ADLs, causing the client to stop taking the medication.
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*Diarrhea is an early manifestation of lithium toxicity q q q q q q q
2. A nurse is updating the plan of care for a client who has bulimia nervosa and is 5%
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above their ideal body weight. Which of the following interventions should the nurse
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include in the plan?
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1. Includea liquidsupplement withmeals. q q q q q
2. Identifytheclient's trigger foods. q q q q
3. Allow the client at least 1 hr for each meal.q q q q q q q q q
4. Weightheclientatbedtimeeachday. q q q q q q
ANS:Correct=2.Identifytheclient'strigger foods.
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- The nurse should identify the trigger foods that initiate the client's binge and assist the client
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to understanding their thoughts and behavior that relate to the food.
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,The nurse should limit the client's meal times to about 30 min to prevent putting excessive
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focus on food.
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The nurse should weigh the client immediately after they wake up and void and prior to oral
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intake. The nurse should weigh the client daily for the first week and then three times per
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week.
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*The nurse should include a liquid supplement for a client who is below their ideal body weight
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and might not be able to eat solid foods at first or might need the additional nutrition to gain
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weight.
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3. A nurse is caring for a client whose child has a terminal illness.The client requests
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information about how to deal with the upcoming loss.Which of the following
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statements should the nurse make?
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, 1. "Itwillbe better foryou tokeepbusytoavoidthinkingaboutyour child's death."
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2. "Youwillcompletethegrievingprocessaboutayearafteryourchild's death."
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3. "The grief process will startonce yourchildactually dies."
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4. "Itisnotuncommontofeel angrytowardyourselforothers."
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ANS:Correct=4. "It is not uncommon to feel angry toward yourself or others."
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-Feelings of blame and angertoward oneself or others arean expected reaction when a client is
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experiencing a loss.
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The grief process has no timeline. It varies for each individual. The
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client can begin anticipatory grieving during the child's illness.
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4. A nurse in a mental health clinic is planning care for a client who has a new
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prescription for olanzapine.Which of the following interventions should the nurse
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identify as the priority?
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1. Advisethe clientto take frequent sipsof water. q q q q q q q q
2. Recommendthattheclient exerciseregularly. q q q q q
3. Consult a dietitian for a calorie-controlleddiet plan. q q q q q q q
4. Instructtheclient toavoiddrivingduringinitial therapy. q q q q q q q q
ANS:Correct=4.Instructtheclient to avoid driving during initial therapy.
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- The greatest risk to this client is injury resulting from drowsiness or dizziness. Therefore, the
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nurse's priority intervention is to instruct the client to avoid activities that require mental
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alertness during initial medication therapy.
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Thenurseshouldadvisetheclient totakefrequent sipsofwaterduetothe adverse effect of dry
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mouth. However, this is not the nurse's priority intervention.
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The nurse should advise the client to exercise regularly due to the adverse effects of weight
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gain andconstipation.However,thisis not the nurse'spriorityintervention. The nurse should
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consult a dietitian for a calorie-controlled diet plan due to the adverse effect of weight gain.
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However, this is not the nurse's priority intervention.
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5. Anurseiscounselinganadolescent whohasanorexianervosaandreports excessive
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laxative use and fear of gaining weight.The Client states, "I'm so fat I can't even stand to
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look at myself.".Which of the following therapeutic responses demonstrates the nurse's
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use of summarizing?
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