Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client admitted for injuries from a motor vehicle crash has a history of bipolar disorder for which he takes lithium. What is a major concern of the nurse?
A. Lithium toxicity is likely in the client’s treatment
Lithium toxicity is a concern but not inevitable. It occurs with levels above 1.5 mEq/L, often due to dehydration or drug interactions, common in trauma settings. However, routine monitoring of levels is a more immediate nursing priority than assuming toxicity, as early detection prevents severe outcomes like seizures or renal damage.
B. Lithium is completely metabolized by the liver so liver function tests are indicated
Lithium is primarily excreted by the kidneys, not metabolized by the liver. Liver function tests are not indicated for lithium monitoring, as it does not undergo hepatic metabolism. This statement is inaccurate, as renal function tests are critical to assess lithium clearance and prevent toxicity in trauma patients.
C. Lithium requirements increase with stress so additional lithium may be required
Stress does not directly increase lithium requirements. Trauma-related dehydration or renal impairment can elevate lithium levels, risking toxicity, but this is due to reduced clearance, not increased need. This statement is inaccurate, as dosing adjustments should be based on serum levels, not stress alone.
D. Lithium has a very narrow therapeutic range so lithium levels should be obtained
Lithium has a narrow therapeutic range (0.6-1.2 mEq/L), and trauma-related factors like dehydration or medications can alter levels, risking toxicity or subtherapeutic effects. Regular serum level monitoring is critical, especially in acute settings, to ensure safety and efficacy, making this statement accurate and a priority nursing concern.
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Full Explanation
Choice A reason: Lithium toxicity is a concern but not inevitable. It occurs with levels above 1.5 mEq/L, often due to dehydration or drug interactions, common in trauma settings. However, routine monitoring of levels is a more immediate nursing priority than assuming toxicity, as early detection prevents severe outcomes like seizures or renal damage.
Choice B reason: Lithium is primarily excreted by the kidneys, not metabolized by the liver. Liver function tests are not indicated for lithium monitoring, as it does not undergo hepatic metabolism. This statement is inaccurate, as renal function tests are critical to assess lithium clearance and prevent toxicity in trauma patients.
Choice C reason: Stress does not directly increase lithium requirements. Trauma-related dehydration or renal impairment can elevate lithium levels, risking toxicity, but this is due to reduced clearance, not increased need. This statement is inaccurate, as dosing adjustments should be based on serum levels, not stress alone.
Choice D reason: Lithium has a narrow therapeutic range (0.6-1.2 mEq/L), and trauma-related factors like dehydration or medications can alter levels, risking toxicity or subtherapeutic effects. Regular serum level monitoring is critical, especially in acute settings, to ensure safety and efficacy, making this statement accurate and a priority nursing concern.
Similar Questions
A client is scheduled for a procedure for treatment of hyperthyroidism. Prior to the procedure, the client will be given medications to reach an euthyroid state. What is the rationale for doing this?
A. Prevent possible hypothyroidism
Achieving euthyroid state before hyperthyroidism procedures, like thyroidectomy, aims to normalize thyroid hormone levels, not prevent hypothyroidism. Post-procedure hypothyroidism is a separate concern managed with hormone replacement. This statement is inaccurate, as the primary goal is to stabilize metabolism, not prevent low thyroid function.
B. Prevent thyroid storm
Medications like methimazole or propylthiouracil are used pre-procedure to achieve euthyroid state, reducing thyroid hormone levels to prevent thyroid storm—a life-threatening hypermetabolic crisis triggered by surgery or stress. This statement is accurate, as stabilizing thyroid function minimizes perioperative complications like tachycardia or hyperthermia.
C. Help medications for hyperthyroidism be more effective
Euthyroid state does not directly enhance the efficacy of anti-thyroid medications but rather prepares the patient for surgery by reducing hyperthyroid symptoms. Medications are effective independently, and this statement is inaccurate, as the rationale focuses on patient safety, not drug potentiation.
D. Minimize the risk of bleeding during the surgical procedure
While euthyroid state reduces metabolic stress, it does not primarily minimize bleeding risk. Bleeding is managed through surgical techniques and coagulation status, not thyroid hormone levels. This statement is inaccurate, as bleeding risk is not the primary concern addressed by achieving euthyroid state pre-procedure.
Full Explanation
Choice A reason: Achieving euthyroid state before hyperthyroidism procedures, like thyroidectomy, aims to normalize thyroid hormone levels, not prevent hypothyroidism. Post-procedure hypothyroidism is a separate concern managed with hormone replacement. This statement is inaccurate, as the primary goal is to stabilize metabolism, not prevent low thyroid function.
Choice B reason: Medications like methimazole or propylthiouracil are used pre-procedure to achieve euthyroid state, reducing thyroid hormone levels to prevent thyroid storm—a life-threatening hypermetabolic crisis triggered by surgery or stress. This statement is accurate, as stabilizing thyroid function minimizes perioperative complications like tachycardia or hyperthermia.
Choice C reason: Euthyroid state does not directly enhance the efficacy of anti-thyroid medications but rather prepares the patient for surgery by reducing hyperthyroid symptoms. Medications are effective independently, and this statement is inaccurate, as the rationale focuses on patient safety, not drug potentiation.
Choice D reason: While euthyroid state reduces metabolic stress, it does not primarily minimize bleeding risk. Bleeding is managed through surgical techniques and coagulation status, not thyroid hormone levels. This statement is inaccurate, as bleeding risk is not the primary concern addressed by achieving euthyroid state pre-procedure.
The nurse is assessing a client with suspected Gastroesophageal Reflux Disease (GERD). Which word or statement is an accurate characteristic of GERD?
A. Melena
Melena, dark tarry stools from digested blood, indicates upper gastrointestinal bleeding, not typically GERD. GERD involves acid reflux causing esophageal irritation, not bleeding severe enough for melena. This statement is inaccurate, as melena is more associated with ulcers or varices, not reflux disease.
B. Heartburn
Heartburn, a burning sensation in the chest, is a hallmark of GERD, caused by stomach acid refluxing into the esophagus, irritating the mucosa. It results from lower esophageal sphincter dysfunction, allowing acid backflow. This statement is accurate, as heartburn is a primary diagnostic symptom of GERD.
C. Hematemesis
Hematemesis, vomiting blood, is not a common GERD symptom but indicates severe conditions like esophageal varices or ulcers. While chronic GERD may lead to esophagitis, bleeding is rare. This statement is inaccurate, as hematemesis is not a characteristic feature of typical GERD presentations.
D. Dysphagia
Dysphagia, difficulty swallowing, can occur in severe GERD due to esophageal strictures or motility issues but is not a primary characteristic. Heartburn is more common and diagnostic. This statement is less accurate, as dysphagia is a complication, not a defining feature of GERD.
Full Explanation
Choice A reason: Melena, dark tarry stools from digested blood, indicates upper gastrointestinal bleeding, not typically GERD. GERD involves acid reflux causing esophageal irritation, not bleeding severe enough for melena. This statement is inaccurate, as melena is more associated with ulcers or varices, not reflux disease.
Choice B reason: Heartburn, a burning sensation in the chest, is a hallmark of GERD, caused by stomach acid refluxing into the esophagus, irritating the mucosa. It results from lower esophageal sphincter dysfunction, allowing acid backflow. This statement is accurate, as heartburn is a primary diagnostic symptom of GERD.
Choice C reason: Hematemesis, vomiting blood, is not a common GERD symptom but indicates severe conditions like esophageal varices or ulcers. While chronic GERD may lead to esophagitis, bleeding is rare. This statement is inaccurate, as hematemesis is not a characteristic feature of typical GERD presentations.
Choice D reason: Dysphagia, difficulty swallowing, can occur in severe GERD due to esophageal strictures or motility issues but is not a primary characteristic. Heartburn is more common and diagnostic. This statement is less accurate, as dysphagia is a complication, not a defining feature of GERD.
What is the physiologic mechanism behind the development of pyrexia?
A. Release of pyrogens resetting the hypothalamic thermostat
Pyrexia (fever) occurs when pyrogens, like cytokines (IL-1, IL-6), released during infection or inflammation, act on the hypothalamus to raise the body’s temperature set point. This triggers heat production via shivering and vasoconstriction, conserving heat to create a fever, enhancing immune response. This statement accurately describes the primary mechanism of pyrexia.
B. Increased peripheral vasoconstriction reducing heat loss
Peripheral vasoconstriction occurs during fever to conserve heat but is a response, not the cause, of pyrexia. It results from hypothalamic signaling after pyrogens reset the thermostat. This statement is inaccurate, as vasoconstriction is a secondary effect, not the initiating physiologic mechanism of fever development.
C. Decreased metabolic rate increasing heat production
Fever increases, not decreases, metabolic rate to generate heat via thermogenesis. Pyrogens elevate the hypothalamic set point, prompting energy expenditure through shivering and muscle activity. This statement is inaccurate, as reduced metabolism would lower body temperature, counteracting the fever response triggered by infection or inflammation.
D. Inhibition of prostaglandin synthesis in the hypothalamus
Prostaglandin synthesis, particularly PGE2, in the hypothalamus is stimulated by pyrogens, raising the temperature set point to cause fever. Inhibiting prostaglandin synthesis (e.g., by NSAIDs) reduces fever, not causes it. This statement is inaccurate, as prostaglandin inhibition opposes the physiologic mechanism of pyrexia.
Full Explanation
Choice A reason: Pyrexia (fever) occurs when pyrogens, like cytokines (IL-1, IL-6), released during infection or inflammation, act on the hypothalamus to raise the body’s temperature set point. This triggers heat production via shivering and vasoconstriction, conserving heat to create a fever, enhancing immune response. This statement accurately describes the primary mechanism of pyrexia.
Choice B reason: Peripheral vasoconstriction occurs during fever to conserve heat but is a response, not the cause, of pyrexia. It results from hypothalamic signaling after pyrogens reset the thermostat. This statement is inaccurate, as vasoconstriction is a secondary effect, not the initiating physiologic mechanism of fever development.
Choice C reason: Fever increases, not decreases, metabolic rate to generate heat via thermogenesis. Pyrogens elevate the hypothalamic set point, prompting energy expenditure through shivering and muscle activity. This statement is inaccurate, as reduced metabolism would lower body temperature, counteracting the fever response triggered by infection or inflammation.
Choice D reason: Prostaglandin synthesis, particularly PGE2, in the hypothalamus is stimulated by pyrogens, raising the temperature set point to cause fever. Inhibiting prostaglandin synthesis (e.g., by NSAIDs) reduces fever, not causes it. This statement is inaccurate, as prostaglandin inhibition opposes the physiologic mechanism of pyrexia.