Author Question: A nurse is assessing a client admitted to the ambulatory surgery unit. The client has diaphoresis ... (Read 52 times)

danielfitts88 · **on:** Jul 22, 2018

A nurse is assessing a client admitted to the ambulatory surgery unit. The client has diaphoresis with rapid pulse and respirations, elevated blood pressure, and dilated pupils.

When the nurse attempts to reinforce preoperative teaching, the client cannot remember anything about previous instructions. Which of these nursing actions is MOST appropriate? a. Administer the prescribed preoperative medication now.
b. Ask the client to describe what is wrong.
c. Slowly repeat all preoperative instructions.
d. Notify the surgeon of the client's emotional status.

Question 2

An older adult client has been taking lithium for several months. The nurse should recognize that the client's age increases susceptibility to which of these potential complications?

a. breakthrough episodes despite appropriate medical management
b. developing lithium toxicity
c. noncompliance with drug regime
d. sodium depletion

peilian · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

D
Mildly anxious clients should receive the most complete instructions. Moderately anxious clients receive less information but more attention to specific areas of concern. Severely anxious clients receive only basic information but are encouraged to verbalize their concerns. Clients in a state of panic are unable to learn; in such cases, no instructions are given and the surgeon is notified.

Answer to Question 2

B
Serum lithium level must be checked at scheduled intervals throughout therapy. Older adult clients may have decreased renal function, which places them at greater risk for developing lithium toxicity.