Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse should monitor the temperature of the environment of a client who becomes easily agitated, with awareness that increased temperatures sometimes may cause the client to become:
A. Calm
High temperatures do not usually cause people to become calm unless they are suffering from heat exhaustion or heat stroke, which are medical emergencies.
B. Depressed
depression is usually associated with low temperatures and reduced sunlight exposure rather than high temperatures.
C. Agitated
high temperatures is associated with arousal and agitation in some individuals which may be due to the effects of heat on the individual’s nervous system, cardiovascular, and endocrine systems.
D. Confused
confusion is not usually associated with confusion. However, it may result in confusion in older adults and individuals with other underlying conditions.
This question is an excerpt from Nurse Dive's nursing test bank - ATI ns 130 Exam Psychosocial Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale: High temperatures do not usually cause people to become calm unless they are suffering from heat exhaustion or heat stroke, which are medical emergencies.
Choice B rationale: depression is usually associated with low temperatures and reduced sunlight exposure rather than high temperatures.
Choice C rationale: high temperatures is associated with arousal and agitation in some individuals which may be due to the effects of heat on the individual’s nervous system, cardiovascular, and endocrine systems.
Choice D rationale: confusion is not usually associated with confusion. However, it may result in confusion in older adults and individuals with other underlying conditions.
Similar Questions
During client teaching, the nurse must inform the client prescribed a tricyclic antidepressant (TCA) to not expect to see a difference in mood or anxiety level for up to:
A. 2-4 weeks
TCAs do not have an immediate mechanism of action and may take approximately 2-4 weeks to have an effect on the neurotransmitters involved in mood regulation hence the brain may take some time to adjust to these changes.
B. 1-2 weeks
1-2 weeks is too short, and may lead clients to feel discouraged or frustrated if they do not see any results by then hence informing them of the duration it will take before they can realize a change in their mood or anxiety is crucial.
C. 3-4 days
3-4 days is too short, and may lead clients to feel discouraged or frustrated if they do not see any results.
D. 1-2 days
1-2 days is too short and unrealistic and gives the client false expectations and may make them think that the drugs are ineffective in their mood and anxiety control.
Full Explanation
Choice A rationale: TCAs do not have an immediate mechanism of action and may take approximately 2-4 weeks to have an effect on the neurotransmitters involved in mood regulation hence the brain may take some time to adjust to these changes.
Choice B rationale: 1-2 weeks is too short, and may lead clients to feel discouraged or frustrated if they do not see any results by then hence informing them of the duration it will take before they can realize a change in their mood or anxiety is crucial.
Choice C rationale: 3-4 days is too short, and may lead clients to feel discouraged or frustrated if they do not see any results.
Choice D rationale: 1-2 days is too short and unrealistic gives the client false expectations and may make them think that the drugs are ineffective in their mood and anxiety control.
In preparing discharge planning for a client who has been prescribed lithium for the treatment of bipolar disorder, the nurse must be sure that the client demonstrates an understanding of the need to monitor his or her diet for intake of:
A. Fats
fats are directly related to lithium therapy and does not require any special monitoring during the drug’s intake.
B. Protein
proteins do not affect the blood levels of lithium hence they do not require any special monitoring during the drug’s intake.
C. Sodium
Lithium is a salt that can affect the fluid and electrolyte balance in the body and competes with sodium for their reabsorption in the kidneys. Therefore, if the client consumes too much or too little sodium, it can alter the level of lithium in the blood and cause toxicity or ineffectiveness hence the need for close monitoring.
D. Potassium
potassium does not affect the blood levels of lithium hence no special monitoring during intake is required.
Full Explanation
Choice A rationale: fats are directly related to lithium therapy and does not require any special monitoring during the drug’s intake.
Choice B rationale: proteins do not affect the blood levels of lithium hence they do not require any special monitoring during the drug’s intake.
Choice C rationale: Lithium is a salt that can affect the fluid and electrolyte balance in the body and competes with sodium for their reabsorption in the kidneys.
Therefore, if the client consumes too much or too little sodium, it can alter the level of lithium in the blood and cause toxicity or ineffectiveness hence the need for close monitoring.
Choice D rationale: potassium does not affect the blood levels of lithium hence no special monitoring during intake is required.
Which laboratory value must be monitored frequently for the client who is on Lithium therapy?
A. Red blood cells
lithium does not affect the levels of red blood cells hence no monitoring is required during its intake.
B. Kidney function
lithium is excreted in the kidneys hence close kidney function monitoring is essential since it prevents lithium toxicity.
C. Hemoglobin and Hematocrit
lithium does not affect the levels of hemoglobin and hematocrit levels hence no frequent monitoring is required during its intake.
D. White Blood Cells
lithium does not affect the levels of white blood cells hence no monitoring is required during its intake.
Full Explanation
Choice A rationale: lithium does not affect the levels of red blood cells hence no monitoring is required during its intake.
Choice B rationale: lithium is excreted in the kidneys hence close kidney function monitoring is essential since it prevents lithium toxicity.
Choice C rationale: lithium does not affect the levels of hemoglobin and hematocrit levels hence no frequent monitoring is required during its intake.
Choice D rationale: lithium does not affect the levels of white blood cells hence no monitoring is required during its intake.