After receiving the assignment for the shift, the nurse plans to ...

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After receiving the assignment for the shift, the nurse plans to assess which client first?
 
  1. The client with mild pain
   2. The client who needs help with ambulation
   3. The client experiencing dyspnea
   4. The client who needs assistance with a bath

Question 2

A client in the manic phase of bipolar disorder is being provided with lithium and has a current level of 0.4. Which of the following will the nurse assess in this client?
 
  1. A decrease in manic behavior
   2. Signs and symptoms of depression
   3. Hyperactivity and pressured speech
   4. A return to baseline behavior, calm and rational

[huda]

Answer to Question 1

3. The client experiencing dyspnea

Rationale:
The nurse begins by assessing the client who is at the greatest risk, who in this case is the client having trouble breathing. The risk for the client with mild pain is not as severe as the client with dyspnea. The nurse can delegate the ambulation of a client to a nursing assistive person. The nurse can also delegate assisting a client who needs help with a bath.

Answer to Question 2

3. Hyperactivity and pressured speech

Rationale:
A therapeutic lithium level is 0.6 to 1.5. Since this client's level is low, behaviors will indicate mania, i.e., hyperactivity and pressured speech. There will be no decrease in manic behavior because the lithium level is too low. The client will not exhibit signs and symptoms of depression, but will continue in the manic phase until the lithium level is within a therapeutic range. The client will not return to baseline behavior, but will continue in the manic phase until the lithium level is within a therapeutic range.

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TYSM

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Gracias!