A client has begun a long-term maintenance therapy with lithium, which has a narrow therapeutic index. Which adverse effect is most important for the nurse to include in the teaching plan?

Dependence.

Interaction.

Toxicity.

Tolerance.

Answer and Explanation

The Correct Answer is C

Choice A reason: Dependence is not a primary concern with lithium, a mood stabilizer. Toxicity is critical due to lithium’s narrow therapeutic range, risking severe complications. Dependence is more relevant to other drugs, per psychopharmacology and lithium therapy education standards in nursing.

Choice B reason: Interactions are important but less urgent than toxicity, which can be life-threatening with lithium’s narrow therapeutic index. Toxicity education emphasizes monitoring blood levels to prevent harm, per psychopharmacology and patient safety protocols in lithium therapy teaching.

Choice C reason: Toxicity is the most critical adverse effect to teach, as lithium’s narrow therapeutic index risks severe complications like seizures or renal failure. Monitoring symptoms and blood levels ensures safety, per evidence-based psychopharmacology and patient education protocols for lithium therapy in nursing.

Choice D reason: Tolerance is not a significant issue with lithium, unlike toxicity, which is life-threatening due to its narrow therapeutic range. Teaching toxicity symptoms prioritizes patient safety, per lithium therapy management and psychopharmacological education standards in nursing practice.

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Correct Answer is B

Explanation

Choice A reason: Electrolyte solutions address dehydration but are inappropriate for pale, cool, lethargic symptoms in Tetralogy of Fallot (TOF), indicating a hypercyanotic spell from right-to-left shunting. Urgent medical intervention restores oxygenation, making this inadequate compared to addressing the critical hypoxic episode requiring provider attention.

Choice B reason: Pale, cool, lethargy in TOF signals a hypercyanotic spell, where pulmonary stenosis increases right-to-left shunting, causing cyanosis and hypoxia. Contacting the provider ensures rapid interventions (e.g., oxygen, beta-blockers), preventing cerebral hypoxia or cardiac arrest, addressing the urgent pathophysiological crisis effectively.

Choice C reason: Quiet time by holding or rocking may calm the toddler but does not treat hypoxic spells in TOF, where pale, cool symptoms indicate shunting and hypoxia. Delaying medical intervention risks severe hypoxia, making this less critical than contacting the provider for urgent management.

Choice D reason: A recumbent position worsens TOF’s hypercyanotic spell, increasing venous return and shunting, exacerbating hypoxia. Knee-chest positioning reduces shunting. Contacting the provider is urgent to address pale, cool, lethargic symptoms, ensuring interventions to restore oxygenation, making this position contraindicated.

A. A client with pancreatitis who has a fasting glucose of 190 mg/dL (10.55 mmol/L) today and had 160 mg/dL (8.88 mmol/L) yesterday. B. A client with a gastrointestinal (GI) bleed who is receiving a blood transfusion and has a hemoglobin of 7.0 g/dL (4.34 mmol/L). C. A client with cancer who has an absolute neutrophil count (ANC) of less than 500/mm3 today and had 2,000/mm3 yesterday. D. A client with hepatitis who is jaundiced and has a bilirubin level that is 4 times the normal value.

Correct Answer is C

Explanation

Choice A reason: Elevated glucose (190 mg/dL) in pancreatitis needs monitoring but is less urgent than severe neutropenia (ANC <500/mm3), which risks life-threatening infections. Glucose can be managed with insulin, per diabetes and pancreatitis care protocols, but neutropenia requires immediate intervention.

Choice B reason: Hemoglobin of 7.0 g/dL in a GI bleed is critical but less immediate, as the client is receiving a transfusion. Neutropenia (ANC <500/mm3) poses an urgent infection risk, requiring isolation. Transfusion addresses anemia, per bleeding and hematology care standards.

Choice C reason: An ANC <500/mm3 indicates severe neutropenia, posing an immediate infection risk in cancer patients, requiring urgent isolation and antibiotics. This rapid drop from 2,000/mm3 demands priority intervention to prevent sepsis, per oncology and infection control protocols in nursing practice.

Choice D reason: Elevated bilirubin in hepatitis is concerning but less urgent than neutropenia (ANC <500/mm3), which risks sepsis. Jaundice requires monitoring and treatment, but severe infection risk takes precedence, per liver disease and critical care prioritization standards in nursing practice.

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A client has begun a long-term maintenance therapy with lithium, which has a narrow therapeutic index. Which adverse effect is most important for the nurse to include in the teaching plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with Tetralogy of Fallot. Which instruction should the nurse give the parents if their child becomes pale, cool, and lethargic?

Correct Answer is B

Explanation

Which client’s laboratory value requires immediate intervention by a nurse? Reference Range: Hemoglobin (Hgb) [14 to 18 g/dL (8.7 to 11.2 mmol/L)]; Fasting Blood Glucose [70 to 110 mg/dL (3.9 to 6.1 mmol/L)]; Neutrophils (ANC) [55 to 70%: 2,500 to 8,000/mm3 (2.5 to 5.8 x109/L)]

Correct Answer is C

Explanation

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