Difficulty: Medium
Average Score: 76%
Simulated
Passage / Scenario
Diagnostic ResultsAdmission: 12 hr later.
ÔÇó Lithium level 1.8 mEq/L (less than 1.5 mEq/L).
ÔÇó Glucose level 90 mg/dL (74 to 106 mg/dL).
ÔÇó Sodium 133 mEq/L (135 to 145 mEq/L).
ÔÇó Lithium level 1.2 mEq/L (less than 1.5 mEq/L).
ÔÇó Glucose level 80 mg/dL (74 to 106 mg/dL).
ÔÇó Sodium 134 mEq/L (135 to 145 mEq/L).
Vital Signs
Admission:
ÔÇó Temperature 37.7┬░ C (99.9┬░ F).
ÔÇó Respiratory rate 18/min.
ÔÇó Pulse rate 84/min.
ÔÇó BP 130/84 mm Hg.
12 hr later:
ÔÇó Temperature 37┬░ C (98.6┬░ F).
ÔÇó Respiratory rate 16/min.
ÔÇó Pulse rate 96/min.
ÔÇó BP 88/50 mm Hg.
Nurses Notes
Admission:
ÔÇó Gastrointestinal upset.
ÔÇó Uncoordinated gait.
12 hr later:
ÔÇó Client fell asleep during assessment.
ÔÇó Client reports blurred vision.
ÔÇó Pale, dry mucous membranes.
ÔÇó Urine output 40 mL/hr.
A nurse is collecting data from the client 12 hr later. How should the nurse interpret the following findings? For each potential finding, click to specify whether the finding is an indication of potential improvement or an indication of potential worsening condition.
Correct answer
A: Potential Worsening, B: Potential Improvement, C: Potential Improvement, D: Potential Worsening, E: Potential Worsening
Rationale
A: Blurred vision indicates potential neurotoxicity. B: Lithium level decrease to 1.2 mEq/L shows improvement. C: Urine output of 40 mL/hr is adequate. D: Pale, dry mucous membranes suggest dehydration. E: Hypotension (88/50 mm Hg) indicates worsening.