A nurse is admitting a client to the mental health unit.

Exhibits

The nurse is developing a plan of care for the client. Which of the following interventions should the nurse include? (Select all that apply.)

A. Walk with the client at a gradually slower pace is the best response. Pacing is a common physical manifestation of anxiety, and walking with the client helps to provide support and structure. By walking with them, you can help them gradually reduce their anxiety in a safe and controlled manner. It also allows you to stay engaged with the client and assess their emotional state.
B. Instruct the client to sit down and stop pacing is not the best approach. Telling the client to stop pacing may increase feelings of frustration or being misunderstood, potentially worsening their anxiety. Clients with generalized anxiety disorder (GAD) may need assistance in managing their anxiety in a supportive way, rather than being told to simply stop.
C. Have a staff member escort the client to her room could be too isolating. While it might seem like a way to help the client calm down, it may not address the underlying anxiety and may make the client feel more isolated or controlled. It is more effective to remain present and help guide the client through managing their anxiety.
D. Allow the client to pace alone until physically tired is not ideal. Although the client may eventually tire from pacing, this approach does not offer the emotional support needed to help manage anxiety. It could also reinforce the behavior and prolong the anxiety rather than helping the client regain control.

A. Check the client's medication record to assess whether the client has been refusing her lithium is not the immediate action needed in this scenario. While it's important to assess adherence to medication, the current lithium level of 1.0 mEq/L is within the therapeutic range (0.6 to 1.2 mEq/L), so there is no immediate concern about toxicity or missed doses at this time.
B. Administer the morning dose of lithium is the correct action. A lithium level of 1.0 mEq/L is within the therapeutic range, so the nurse can safely administer the scheduled dose of lithium. Routine monitoring is important, but this level is not cause for concern at this time.
C. Hold the medication and assess for early manifestations of toxicity is unnecessary. The lithium level of 1.0 mEq/L is within the therapeutic range. Early signs of toxicity usually begin when levels exceed 1.5 mEq/L, so there are no signs that would warrant withholding the medication at this time.
D. Prepare for gastric lavage due to an extremely elevated lithium level is incorrect. A lithium level of 1.0 mEq/L is not elevated to the point of requiring gastric lavage. Toxicity is typically a concern when levels exceed 1.5 mEq/L, so there is no need for such an intervention.