A nurse in a mental health clinic is caring for a client who has bipolar disorder and
reports that they stopped taking lithium 2 weeks ago. The nurse
... [Show More] should recognize
which of the following as an expected adverse effect that might have caused the
client to spot taking the medication?
1. Sore throat
2. Photophobia
3. Hand tremors
4. Constipation - Correct = 3. Hand Tremors
- Fine hand tremors are an expected adverse effect of lithium and can interfere with
performance of ADLs, causing the client to stop taking the medication.
*Diarrhea is an early manifestation of lithium toxicity
A nurse is updating the plan of care for a client who has bulimia nervosa and is 5%
above their ideal body weight. Which of the following interventions should the nurse
include in the plan?
1. Include a liquid supplement with meals.
2. Identify the client's trigger foods.
3. Allow the client at least 1 hr for each meal.
4. Weigh the client at bedtime each day. - Correct = 2. Identify the client's trigger
foods.
- The nurse should identify the trigger foods that initiate the client's binge and assist
the client to understanding their thoughts and behavior that relate to the food.
The nurse should limit the client's meal times to about 30 min to prevent putting
excessive focus on food.
The nurse should weigh the client immediately after they wake up and void and prior
to oral intake. The nurse should weigh the client daily for the first week and then
three times per week.
*The nurse should include a liquid supplement for a client who is below their ideal
body weight and might not be able to eat solid foods at first or might need the
additional nutrition to gain weight.
A nurse is caring for a client whose child has a terminal illness. The client requests
information about how to deal with the upcoming loss. Which of the following
statements should the nurse make?
1. "It will be better for you to keep busy to avoid thinking about your child's death."
2. "You will complete the grieving process about a year after your child's death."
3. "The grief process will start once your child actually dies."
4. "It is not uncommon to feel angry toward yourself or others." - Correct = 4. "It is
not uncommon to feel angry toward yourself or others."
- Feelings of blame and anger toward oneself or others are an expected reaction
when a client is experiencing a loss.
The grief process has no timeline. It varies for each individual.
The client can begin anticipatory grieving during the child's illness.
A nurse in a mental health clinic is planning care for a client who has a new
prescription for olanzapine. Which of the following interventions should the nurse
identify as the priority?
1. Advise the client to take frequent sips of water.
2. Recommend that the client exercise regularly.
3. Consult a dietitian for a calorie-controlled diet plan. [Show Less]