A nurse in a mental health facility is collecting data from a client who is taking lithium. Which of the following findings should the nurse report to the provider as an indication of lithium toxicity?
Slurred speech
Stooped posture
Elevated blood pressure
Dry cough
The Correct Answer is A
A. Slurred speech can be a symptom of lithium toxicity. As lithium levels rise in the blood, it can affect neurological function, leading to symptoms such as confusion, drowsiness, tremors, and slurred speech.
B. Stooped posture is not typically associated with lithium toxicity. It is more commonly associated with musculoskeletal issues or neurological disorders rather than lithium toxicity.
C. Elevated blood pressure is not a typical symptom of lithium toxicity. Lithium can actually have a protective effect on blood pressure, and hypertension is not commonly associated with lithium toxicity.
D. Dry cough is not a symptom of lithium toxicity. It is more commonly associated with respiratory conditions or medication side effects rather than lithium toxicity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. When administering a TST, the nurse should select an injection site that is free of scar tissue and areas with excessive hair, veins, or visible lesions. The preferred site for TST administration is the volar aspect of the forearm, approximately 2-4 inches below the elbow.
B. After administering the TST, the nurse should not massage or manipulate the injection site. Massaging the site can cause irritation or spread the solution, leading to inaccurate results.
C. he TST is administered intradermally, typically with a 27-gauge needle. The needle should be inserted with the bevel facing upward at a 5-15-degree angle.
D. The standard dose of tuberculin solution (e.g., purified protein derivative, PPD) for a TST is 0.1 mL containing 5 tuberculin units (TU).
Correct Answer is A
Explanation
A. According to the recommended immunization schedule, the second dose of the MMR vaccine is typically administered at 4 to 6 years of age, before starting school. This booster dose helps ensure long- term immunity against measles, mumps, and rubella.
B. The MMR vaccine is typically administered in two doses: the first dose at 12 to 15 months of age and the second dose at 4 to 6 years of age. There is no need for additional MMR immunizations over the next 2 years if the child receives the recommended doses.
C. While the child may receive additional immunizations at 3 years of age, such as the hepatitis B vaccine, the second dose of the MMR vaccine is typically administered at 4 to 6 years of age, not 3 years.
D. Titer testing is typically not recommended for determining the need for further MMR immunizations in young children. The immunization schedule provides specific recommendations for MMR vaccine doses based on age, rather than individual titers.
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