A nurse assesses a patient who takes lithium. Which findings demonstrate evidence of complications?
a. Pharyngitis, mydriasis, and dystonia
b. Alopecia, purpura, and drowsiness
c. Diaphoresis, weakness, and nausea
d. Ascites, dyspnea, and edema
ANS: C
Diaphoresis, weakness, and nausea are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy.
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When assessing a patient diagnosed with angina pectoris it is most important for the nurse to gather what information?
A) The patient's activities limitations and level of consciousness after the attacks B) The patient's symptoms and the activities that precipitate attacks C) The patient's understanding of the pathology of angina D) The patient's coping strategies surrounding the attacks
A patient has been comatose and in the intensive care unit since having a stroke four days ago. Palliative care interventions were formally initiated yesterday. The nurse would evaluate that these strategies were effective if which situations occur?
1. The family begins to ask questions about requesting a do-not-resuscitate order. 2. The need for a family meeting has been eliminated. 3. The patient is less restless. 4. The primary physician and neurologist consult agree that the patient's prognosis is grim. 5. The patient's daughter asks that the nurse not allow the patient's ex-husband to visit.
The most important factor in setting behavioral goals is
a. the client's willingness to exercise. b. individual habits and preferences. c. the amount of weight loss desired. d. the skill of the health practitioner.
Marnie is a 16-year-old patient with bipolar disorder. She is manic right now and is in the hallway naked, making sexual requests of staff and other patients. What is your best course of action?
A) Quietly approach her, escort her to her room, and assist her to get dressed. B) Quietly approach her, escort her to her room, and explain to her the inappropriateness of her actions. C) Approach her, confront her behavior as it is happening, and escort her to her room. D) Confront her behavior in the hall, apologize to the other patients, and escort her to her room.