Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?
A. Five-pound (2.3 kg) weight gain.
rationale: A five-pound weight gain in a client taking lithium carbonate is significant. however, the timeframe of the weightgain is to be known.
B. Nausea and vomiting.
rationale: Nausea and vomiting are known side effects of lithium that should be reported as they can cause electrolyte imbalance.
C. Short-term memory loss.
rationale: Short-term memory loss is a potential side effect of lithium, but it may not require immediate reporting unless it significantly affects the client's daily functioning or is associated with other concerning symptoms.
D. Depressed affect.
rationale: A depressed affect is a symptom that should be addressed as part of the client's ongoing psychiatric care, but it may not warrant immediate reporting unless it is severe and requires a change in the treatment plan. The priority in this case is the potential lithium toxicity indicated by the weight gain.
This question is an excerpt from Nurse Dive's nursing test bank - Rn Hesi Mental Health Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
A five-pound weight gain in a client taking lithium carbonate is significant. however, the timeframe of the weightgain is to be known. Choice B rationale:
Nausea and vomiting are known side effects of lithium that should be reported as they can cause electrolyte imbalance.
Choice C rationale:
Short-term memory loss is a potential side effect of lithium, but it may not require immediate reporting unless it significantly affects the client's daily functioning or is associated with other concerning symptoms.
Choice D rationale:
A depressed affect is a symptom that should be addressed as part of the client's ongoing psychiatric care, but it may not warrant immediate reporting unless it is severe and requires a change in the treatment plan. The priority in this case is the potential lithium toxicity indicated by the weight gain.
Similar Questions
A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?
A. Teach the client to develop a plan for daily structured activities.
rationale: Teaching the client to develop a plan for daily structured activities is a key intervention for addressing major depressive disorder with symptoms like psychomotor retardation, hypersomnia, and motivation. Structured activities can help the client regain a sense of purpose, improve motivation, and gradually return to a normal level of functioning.
B. Encourage the client to exercise.
rationale: Encouraging exercise is generally beneficial for mental health, but it may not be the most effective intervention for addressing the specific symptoms mentioned in this scenario.
C. Suggest that the client develop a list of pleasurable activities.
rationale: Suggesting the client develop a list of pleasurable activities is a valuable intervention but may not directly address the psychomotor retardation and hypersomnia seen in this case.
D. Provide education on methods to enhance sleep.
rationale: Providing education on methods to enhance sleep is important, especially if hypersomnia is a symptom, but it should be part of a broader treatment plan that also includes addressing psychomotor retardation and motivation.
Full Explanation
Choice A rationale:
Teaching the client to develop a plan for daily structured activities is a key intervention for addressing major depressive disorder with symptoms like psychomotor retardation, hypersomnia, and motivation. Structured activities can help the client regain a sense of purpose, improve motivation, and gradually return to a normal level of functioning.
Choice B rationale:
Encouraging exercise is generally beneficial for mental health, but it may not be the most effective intervention for addressing the specific symptoms mentioned in this scenario.
Choice C rationale:
Suggesting the client develop a list of pleasurable activities is a valuable intervention but may not directly address the psychomotor retardation and hypersomnia seen in this case.
Choice D rationale:
Providing education on methods to enhance sleep is important, especially if hypersomnia is a symptom, but it should be part of a broader treatment plan that also includes addressing psychomotor retardation and motivation.
A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?
A. Compromised family coping.
rationale: Compromised family coping may be a concern, but it is not the most immediate priority given the client's symptoms of altered reality.
B. Ineffective sexual patterns.
rationale: Ineffective sexual patterns is not the primary concern in this scenario, as the client's delusional beliefs and hallucinations take precedence.
C. Impaired environmental interpretation.
rationale: Impaired environmental interpretation may be relevant, but it is not the most immediate priority compared to addressing the client's altered perception of reality.
D. Disturbed sensory perception.
rationale: The client's delusional beliefs and hallucinatory experiences suggest disturbed sensory perception, which is a priority nursing problem that requires immediate attention and intervention. These symptoms may indicate a serious mental health condition, such as psychosis, that necessitates psychiatric evaluation and care.
Full Explanation
Choice A rationale:
Compromised family coping may be a concern, but it is not the most immediate priority given the client's symptoms of altered reality.
Choice B rationale:
Ineffective sexual patterns is not the primary concern in this scenario, as the client's delusional beliefs and hallucinations take precedence.
Choice C rationale:
Impaired environmental interpretation may be relevant, but it is not the most immediate priority compared to addressing the client's altered perception of reality.
Choice D rationale:
The client's delusional beliefs and hallucinatory experiences suggest disturbed sensory perception, which is a priority nursing problem that requires immediate attention and intervention. These symptoms may indicate a serious mental health condition, such as psychosis, that necessitates psychiatric evaluation and care.
The mother of an 8-month-old infant with profound mental and physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth and development milestones. How should the nurse respond to this mother?
A. Encourage the mother to write thoughts and feelings in a journal.
Encouraging journaling may help with coping over time but does not address potential immediate safety concerns.
B. Determine if the mother has other children who do not have developmental disabilities.
Asking about other children is not relevant to the mother’s current emotional state and does not assess risk.
C. Reassure the mother that her child will achieve some growth and development milestones.
Reassuring the mother about milestones may minimize her feelings and does not address her depression or potential risk of harm.
D. Ask the mother if she has ever thought about harming herself or her child.
Asking the mother if she has ever thought about harming herself or her child is the priority response because it assesses for immediate risk of harm. Screening for suicidal or homicidal thoughts is essential when a parent expresses intense depression or hopelessness regarding a child’s condition.
Full Explanation
A. Encouraging journaling may help with coping over time but does not address potential immediate safety concerns.
B. Asking about other children is not relevant to the mother’s current emotional state and does not assess risk.
C. Reassuring the mother about milestones may minimize her feelings and does not address her depression or potential risk of harm.
D. Asking the mother if she has ever thought about harming herself or her child is the priority response because it assesses for immediate risk of harm. Screening for suicidal or homicidal thoughts is essential when a parent expresses intense depression or hopelessness regarding a child’s condition.