Question

A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?

Answer 1

Correct Answers:

“I can't call a doctor in the middle of the night unless it's an emergency."

Rationale :

🧠 Clients with bipolar disorder (mania) often exhibit poor judgment, impulsivity, and demanding behavior.

🧠 The nurse’s response must set clear, firm limits while remaining calm and respectful.

🧠 This statement provides reality-based information without confrontation or judgment.

🧠 It avoids reinforcing inappropriate demands while maintaining safety and structure.

🧠 Consistent limit-setting is essential for managing manic behavior and preventing escalation.

🧠 Why the other options are not correct:

🧠 Saying the client is “very upset” validates emotion but does not set limits, reinforcing behavior.

🧠 Calling the client unreasonable is confrontational and escalates agitation.

🧠 Promising to contact the provider reinforces manipulative behavior and lacks structure.

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Answer 2

Correct Answers:

Family history

Rationale :

🪨 Urolithiasis (kidney stones) has a strong genetic predisposition.

🪨 A family history significantly increases an individual’s risk of stone formation.

🪨 Genetic factors influence urine composition and stone-forming tendencies.

🪨 Clients with family history often develop stones earlier and more frequently.

🪨 Identifying this risk supports early prevention and education.

🪨 Why the other options are not correct:

🪨 Diuretics may reduce stone risk by decreasing calcium concentration in urine.

🪨 A BMI less than 25 is not a risk factor; obesity increases risk.

🪨 Hypocalcemia does not contribute to stone formation; hypercalcemia does.

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Answer 3

Correct Answers:

Facial edema

Rationale :

❄️ Myxedema is caused by severe hypothyroidism.

❄️ Decreased thyroid hormone leads to accumulation of mucopolysaccharides in tissues.

❄️ This causes non-pitting facial edema, especially around the eyes.

❄️ Facial swelling is a classic and distinguishing finding.

❄️ Recognition is essential to prevent progression to myxedema coma.

❄️ Why the other options are not correct:

❄️ Heat intolerance is associated with hyperthyroidism, not hypothyroidism.

❄️ Diarrhea occurs with increased metabolism, not decreased.

❄️ Tachycardia is typical of hyperthyroidism; myxedema causes bradycardia.

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Answer 4

Correct Answers:

Weigh the client daily.

Rationale :

🧂 Addison’s disease causes deficiency of aldosterone, leading to sodium and fluid loss.

🧂 Daily weights help monitor fluid volume status accurately.

🧂 Sudden weight loss may indicate impending Addisonian crisis.

🧂 Early detection allows rapid intervention with fluids and corticosteroids.

🧂 Weight monitoring is a key safety measure in adrenal insufficiency.

🧂 Why the other options are not correct:

🧂 Fluid restriction worsens dehydration and hypotension.

🧂 Diuretics further deplete sodium and fluid, increasing crisis risk.

🧂 Low-carbohydrate diets do not address the primary risk of fluid loss.

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Answer 5

Correct Answers:

Experience with legal system since teenage years
Adhering to financial responsibilities
Relationship with family
Acceptance of responsibility
Substance use

Rationale :

✅ Experience with legal system since teenage years

🧩 A key diagnostic feature of antisocial personality disorder (ASPD) is a long pattern of violating social norms and laws, beginning in adolescence.

🧩 The record shows criminal behavior since the teen years (shoplifting, marijuana sale/possession, auto theft) and juvenile detention, which strongly supports an early onset pattern.

🧩 ASPD often includes repeated arrests and contact with the legal system due to impulsive and irresponsible behaviors.

🧩 This “early-start, persistent pattern” is highly consistent with ASPD criteria.

🧩 The continued issues into adulthood reinforce that it is not an isolated event but a longstanding behavioral style.

✅ Adhering to financial responsibilities (in this case: NOT adhering)

🧩 ASPD commonly involves irresponsibility, including repeated failure to sustain consistent work or honor financial obligations.

🧩 The client has no permanent home after eviction for failure to pay rent, which reflects poor follow-through with basic responsibilities.

🧩 This pattern can come from impulsivity, disregard for consequences, or prioritizing immediate wants over obligations.

🧩 Financial instability is not diagnostic by itself, but paired with legal problems and blame-shifting, it becomes highly suggestive.

🧩 In ASPD, lack of responsibility is often chronic and affects housing, employment, and relationships.

✅ Relationship with family

🧩 The client is estranged from family members, which aligns with the interpersonal pattern often seen in ASPD.

🧩 People with ASPD may have unstable or fractured relationships due to conflict, exploitation, irritability, and lack of empathy.

🧩 Estrangement can reflect longstanding behavior that damages trust and support systems.

🧩 While estrangement alone is not enough for diagnosis, it supports the broader pattern of impaired social bonds.

🧩 This fits especially well when paired with the client’s contemptuous attitude toward others (“crazies,” “losers”).

✅ Acceptance of responsibility (in this case: LACK of responsibility)

🧩 A hallmark of ASPD is failing to show remorse and demonstrating lack of responsibility for one’s actions.

🧩 The client blames others: “That car wreck was not my fault,” and “That judge just has it out for me,” which reflects externalization.

🧩 This response pattern often accompanies repeated rule-breaking—people with ASPD frequently rationalize behavior rather than acknowledging harm.

🧩 Lack of accountability interferes with behavior change because consequences are attributed to unfair systems or other people.

🧩 Clinically, this is a strong behavioral clue supporting ASPD traits.

✅ Substance use

🧩 ASPD is commonly associated with substance misuse and risky behaviors due to impulsivity and disregard for safety.

🧩 The client was arrested for driving under the influence of alcohol, which is consistent with impaired judgment and risk-taking.

🧩 The history of possession and sale of marijuana supports ongoing rule violation and illegal activity.

🧩 Substance use can worsen aggression, poor impulse control, and legal problems—frequent overlaps with ASPD.

🧩 While substance use is not required for ASPD, it is a very common co-occurring pattern.

Findings that are NOT consistent (do NOT select)

❌ Employment status

🧩 Having a job (food delivery) does not, by itself, support or rule out ASPD.

🧩 Some individuals with ASPD can maintain employment, especially when it offers autonomy or minimal supervision.

🧩 Employment status becomes relevant only if the record shows repeated job loss, chronic irresponsibility at work, or exploitation, which is not explicitly stated here.

🧩 So this item is neutral based on the provided record.

❌ Compassion toward others

🧩 ASPD is associated with lack of empathy, manipulation, and disregard for others’ feelings or rights.

🧩 The client’s behavior shows contempt (snickering, calling others “losers”), not compassion.

🧩 Since “compassion toward others” is the opposite of typical ASPD traits, it would not be selected as consistent.

❌ Rechanneling anger with physical activity

🧩 Using exercise to cope (“running helps me not feel so angry”) is a healthy coping strategy, not a core ASPD trait.

🧩 It may reflect an attempt to manage irritability, but it does not demonstrate deceit, exploitation, or lack of remorse.

🧩 This behavior is generally adaptive and can be encouraged as part of anger management.

🧩 Therefore, it is not a defining indicator of ASPD in a medical record.

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Answer 6

Correct Answers:

Dehydration

Rationale :

🪨 Dehydration concentrates urine, increasing the saturation of stone-forming substances such as calcium, oxalate, and uric acid.

🪨 Concentrated urine promotes crystal formation and aggregation, which can grow into renal calculi.

🪨 Inadequate fluid intake is one of the most common and modifiable risk factors for kidney stones.

🪨 Adequate hydration dilutes urine and helps flush minerals before stones can form.

🪨 Teaching clients to maintain sufficient fluid intake is a cornerstone of prevention.

🪨 Why the other options are not correct:

🪨 Protein in the urine reflects kidney disease, not stone formation risk.

🪨 Iron deficiency does not contribute to stone development.

🪨 Obesity can be associated with stones, but dehydration is the primary risk factor emphasized in teaching.

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Answer 7

Correct Answers:

“I will need to wipe my perineal area from back to front after urination."

Rationale :

🚽 Proper perineal hygiene requires wiping from front to back.

🚽 Wiping back to front transfers bacteria from the anal area to the urethra.

🚽 This practice increases the risk of urinary tract infection.

🚽 Teaching correct wiping technique is essential, especially for females.

🚽 The client’s statement indicates incorrect understanding.

🚽 Why the other options are not correct:

🚽 Emptying the bladder regularly reduces urinary stasis and infection risk.

🚽 Adequate fluid intake helps flush bacteria from the urinary tract.

🚽 Apple cider vinegar is not standard teaching, but it does not directly increase UTI risk.

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Answer 8

Correct Answers:

Dysrhythmias

Rationale :

💊 Haloperidol, a first-generation antipsychotic, can prolong the QT interval on the ECG.

💊 QT prolongation increases the risk for serious cardiac dysrhythmias, including torsades de pointes.

💊 This risk is higher with PRN use for agitation, higher doses, or IV administration.

💊 Dysrhythmias can be life-threatening and may occur without early warning symptoms.

💊 Ongoing cardiac assessment is a critical nursing responsibility when administering haloperidol.

💊 Why the other options are not correct:

💊 Pancreatitis is not a known adverse effect of haloperidol.

💊 Cataracts are not associated with antipsychotic therapy.

💊 Bleeding is not a typical or expected effect of haloperidol.

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Answer 9

Correct Answers:

Dehydration

Rationale :

💧 Diabetes insipidus is caused by deficiency or resistance to antidiuretic hormone (ADH).

💧 Without ADH, the kidneys cannot concentrate urine, leading to excessive urine output.

💧 Large fluid losses result in dehydration.

💧 Clients often experience intense thirst (polydipsia) and dilute urine.

💧 Recognizing dehydration is critical to prevent shock and electrolyte imbalance.

💧 Why the other options are not correct:

💧 Polyphagia is associated with diabetes mellitus, not diabetes insipidus.

💧 Hyperglycemia occurs in diabetes mellitus, not DI.

💧 Bradycardia is not a typical finding; tachycardia may occur with dehydration.

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Answer 10

Correct Answers:

Administer the morning dose of lithium.

Rationale :

🧠 The therapeutic range for lithium is approximately 0.6–1.2 mEq/L.

🧠 A level of 1.0 mEq/L is therapeutic, not toxic.

🧠 There are no indications of toxicity in the scenario.

🧠 Holding lithium is unnecessary and could destabilize mood.

🧠 The nurse should safely administer the scheduled dose.

🧠 Why the other options are not correct:

🧠 Checking refusal history is unnecessary when levels are therapeutic.

🧠 Toxicity assessment is not indicated at this level.

🧠 Gastric lavage is reserved for severe lithium toxicity, which is not present.

Distractor Analysis :

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QLexNursing

1 :
A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?

2 :
A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor?

3 :
A nurse is assessing a client who has myxedema. Which of the following findings should the nurse expect?

4 :
A nurse is caring for a client who has Addison's disease and is at risk for Addisonian crisis. Which of the following actions should the nurse take?

5 :
A nurse in a mental health facility is caring for a young adult client.

Answer Options

6 :
A nurse is teaching a client who has urolithiasis (renal calculi). The nurse should explain that which of the following conditions can increase the risk for renal calculi?

7 :
A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching?

8 :
A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects?

9 :
A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

10 :
A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?

QLexNursing

1 : A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?

2 : A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor?

3 : A nurse is assessing a client who has myxedema. Which of the following findings should the nurse expect?

4 : A nurse is caring for a client who has Addison's disease and is at risk for Addisonian crisis. Which of the following actions should the nurse take?

5 : A nurse in a mental health facility is caring for a young adult client.

Answer Options

6 : A nurse is teaching a client who has urolithiasis (renal calculi). The nurse should explain that which of the following conditions can increase the risk for renal calculi?

7 : A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching?

8 : A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects?

9 : A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

10 : A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?

1 :
A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?

2 :
A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor?

3 :
A nurse is assessing a client who has myxedema. Which of the following findings should the nurse expect?

4 :
A nurse is caring for a client who has Addison's disease and is at risk for Addisonian crisis. Which of the following actions should the nurse take?

5 :
A nurse in a mental health facility is caring for a young adult client.

6 :
A nurse is teaching a client who has urolithiasis (renal calculi). The nurse should explain that which of the following conditions can increase the risk for renal calculi?

7 :
A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching?

8 :
A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects?

9 :
A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

10 :
A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?