Difficulty: Medium Average Score: 77% Simulated

Passage / Scenario

NursesÔÇÖ Notes
Admission:
ÔÇó Gastrointestinal upset
ÔÇó Uncoordinated gait
ÔÇó Client fell asleep during assessment
12 hr later:
ÔÇó Client reports blurred vision
ÔÇó Pale, dry mucous membranes
ÔÇó Urine output 40 mL/hr
Medical History
ÔÇó History of bipolar disorder
ÔÇó Water toxicity
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 mmHg
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
Diagnostic Results
Admission:
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)
12 hr later:
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)

The nurse is collecting data from the client 12 hr. later. How should the nurse interpret the following findings? For each potential finding, specify whether the finding is an indication of potential improvement or an indication of potential worsening condition.

The nurse is collecting data from the client 12 hr. later. How should the nurse interpret the following findings? For each potential finding, specify whether the finding is an indication of potential improvement or an indication of potential worsening condition.

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