A home health nurse has a patient who is taking lithium. What should be included in the teaching plan?
Take her blood pressure twice a day to check for hypertension.
Have her drug blood level checked every month.
Avoid aged cheese and red wine.
Examine her skin closely for eruptions.
The Correct Answer is B
A. Take her blood pressure twice a day to check for hypertension. Lithium does not typically cause hypertension. Monitoring blood pressure is not a primary concern for patients on lithium.
B. Have her drug blood level checked every month. Regular monitoring of lithium blood levels is crucial to ensure therapeutic levels and avoid toxicity. Lithium has a narrow therapeutic window, and frequent monitoring helps in adjusting the dose to maintain safe and effective levels.
C. Avoid aged cheese and red wine. This advice is relevant for patients taking MAOIs, not lithium. There is no need for patients on lithium to avoid these foods specifically.
D. Examine her skin closely for eruptions. While skin eruptions can be a side effect of some medications, it is not a primary concern for patients on lithium. The focus should be on monitoring for signs of lithium toxicity and other common side effects like tremors, thyroid dysfunction, and renal impairment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Site of the lesions: The site of the lesions is addressed by the "S" in some mnemonics, but in PQRST, it refers to severity.
B. Severity of the symptoms: In the PQRST mnemonic for pain assessment, "S" stands for severity, referring to how intense or bothersome the symptoms are.
C. Surface area of the lesions: Surface area is not typically included in the PQRST mnemonic but may be relevant for other assessments.
D. Symptomatology of the lesions: Symptomatology encompasses the overall symptoms but is not specifically what "S" represents in PQRST.
Correct Answer is B
Explanation
A. "What we say can be secret. What I write in the chart is available to the health team." This response lacks clarity about legal and ethical obligations.
B. "I am required to report any intent to hurt yourself or others." This response clearly communicates the legal and ethical obligation to protect the patient and others from harm, while also acknowledging the importance of patient confidentiality in other situations.
C. "Conversations between patient and nurse are confidential." This is true, but it does not address exceptions such as harm to self or others.
D. "I can't help you unless you trust me." This does not address the patient's concerns about confidentiality directly.
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