A male client with bipolar disorder who takes lithium tells the nurse that he has been "nauseous a lot lately," feels tired, and has had "some blurry vision." The client most likely is suffering from what level of lithium toxicity?
a. Insignificant
b. Mild
c. Moderate
d. Severe
C
These are signs of symptoms of moderate lithium toxicity, with blood serum levels of 1.5 to 2.5 mEq/L. Additional signs and symptoms of moderate toxicity include ringing in the ears, irregular tremors, and frank muscle twitching. "Insignificant" is not a level of toxicity. Mild and severe levels of toxicity have signs and symptoms different from those of moderate toxicity.
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The nurse is interviewing the client. Which interaction could lead to a communication breakdown between the nurse and client? Select all that apply
1. The client is a Native American and the nurse is of Northern European descent. 2. During the interview, the nurse is trying to remember what the healthcare provider asked her to do earlier in the day. 3. The young nurse creates an informal atmosphere to discuss safe sexual practices with a teenaged client. 4. The young nurse uses a serious and respectful tone to discuss erectile dysfunction with an older client. 5. The nurse states, "So, you experience pain with micturition."
Nausea, vomiting, and an irregular heart rate develop in a patient who takes oral digoxin every morning. What is the nurse's best action?
a. Give prescribed diphenhydramine (Phenergan) as needed. b. Check the patient's cardiac monitor strip. c. Assess the apical pulse for a full minute. d. Check laboratory results for a digoxin level.
The registered nurse (RN) gives an inaccurate dose of a medication to a client. Following an assessment of the client, the nurse completes an incident report
The RN notifies the nursing su-pervisor of the medication error and calls the physician to report the occurrence. The nurse who administered the inaccurate medication dose understands that the: 1. Error will result in suspension. 2. Incident will be reported to the board of nursing. 3. Incident will be documented in the personnel file. 4. Incident report is a method of promoting quality care and risk management.
A patient is blind. You are assisting the person with ambulation. Which action is unsafe?
a. Telling the person when you are coming to a curb or steps b. Telling the person when to step up or down c. Having the person walk slightly behind you d. Using phrases like "over here" or "over there"