The patient is receiving lithium (Eskalith) and asks the nurse why he has to have blood drawn so often. What is the best response by the nurse?
1. "To detect side effects before they become a problem."
2. "To be sure the medication is working properly."
3. "To determine if your body is responding as it should."
4. "To be sure you have the correct amount of medication in your system."
Correct Answer: 4
Rationale: Medications, such as lithium (Eskalith), with a narrow therapeutic range must be monitored with lab tests; this is how the correct dosage is determined. A lab test will not confirm that the medication is working properly; assessment of the patient confirms this. Body response to the medication is best determined by patient assessment. Side effects are best determined by patient assessment.
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The young woman with severe jaundice has a nursing diagnosis of altered body image related to jaundice. When the patient says, "Will I always be this horrible color?" the nurse replies:
1. "Yes, but your sclera will return to their previous white color." 2. "No. The color will fade gradually as liver inflammation decreases." 3. "Yes, but cosmetics can disguise the color." 4. "No, the color will change to freckles."
The clinic nurse is preparing a client for a physical and breast examination. The nurse notes the client's breast appears as shown in the photograph below. Which action by the nurse takes prior-ity?
a. Continue preparations and note the find-ing in the client's chart. b. Ask the client how long this problem has been present. c. Alert the health care provider and prepare to order a mammogram. d. Question the client about routine drug and alcohol intake.
A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement, Risk for falls?
a. Encourage patient to remain in bed most of the shift. b. Keep all side rails down at all times. c. Place patient in room away from the nurses' station if possible. d. Assist patient into and out of bed every 6 hours or as tolerated.
During her first months of pregnancy, a patient tells the nurse, "It seems like I have to go to the bathroom every 5 minutes." The nurse explains to the patient that this is because:
1. The patient probably has a urinary tract infection. 2. Bladder capacity increases throughout pregnancy. 3. The growing uterus puts pressure on the bladder. 4. Some women are very sensitive to body function changes.