A nurse asks a client who is suicidal to make a safety contract, but the client declines.

Which of the following actions should the nurse identify as the priority?.

Assign a staff member to stay with the client at all times.

Lock the doors to the unit and secure windows so they cannot be opened.

Remove any objects from the client's environment that could be used for self-harm.

Provide the client with plastic eating utensils for meals.

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Assigning a staff member to stay with the client at all times is the priority action when a client declines to make a safety contract. This is because the immediate safety of the client is the primary concern in such situations.
Choice B rationale:
Locking the doors to the unit and securing windows so they cannot be opened might be considered a safety measure, but it is not the priority. The focus should be on direct supervision to ensure safety.
Choice C rationale:
Removing any objects from the client’s environment that could be used for self-harm is important, but it is not the priority. The immediate safety of the client through constant supervision is the priority.
Choice D rationale:
Providing the client with plastic eating utensils for meals is a safety measure, but it is not the priority. The immediate safety of the client through constant supervision is the priority.

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Correct Answer is D

Explanation

Choice A rationale:
Diarrhea is not a specific reason to stop lithium. However, severe diarrhea can affect lithium levels and should be reported to a healthcare provider.
Choice B rationale:
Lithium does not need to be taken on an empty stomach. It can be taken with or without food.
Choice C rationale:
A low-salt diet is not recommended while on lithium. In fact, a consistent, normal sodium intake is important because low sodium levels can cause lithium levels to become too high.
Choice D rationale:
Regular blood tests are necessary when taking lithium to ensure therapeutic levels and prevent toxicity. Weekly blood tests may be required during the first month of treatment.

A. Drinking green tea. B. Exercising moderately. C. Increasing sodium intake. D. Experiencing diarrhea.

Correct Answer is D

Explanation

Choice A rationale:

Drinking green tea does not directly cause lithium toxicity.

Choice B rationale:

Moderate exercise does not directly cause lithium toxicity.

Choice C rationale:

Increasing sodium intake does not directly cause lithium toxicity. In fact, a sudden decrease in sodium intake can increase the risk of lithium toxicity.

Choice D rationale:

Experiencing diarrhea can lead to dehydration, which increases the risk of lithium toxicity by reducing the excretion of lithium.

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A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to teach a client about his prescription of lithium for the treatment of bipolar disorder. Which of the following statements should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?

Correct Answer is D

Explanation

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A nurse asks a client who is suicidal to make a safety contract, but the client declines.

Which of the following actions should the nurse identify as the priority?.