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.)

Notify the provider of potential medication interactions.

Discuss contraception with the client.

Set up a dietary consult for a low-sodium diet.

Educate the client about the need for hemodialysis.

Administer prochlorperazine.

Withhold next dose of lithium.

Answer and Explanation

Correct Answer : A,E,F

A. Notify the provider of potential medication interactions: Furosemide, a loop diuretic, and NSAIDs like ibuprofen can increase lithium levels, contributing to toxicity. Notifying the provider is essential to reassess the medication regimen, especially with current signs of toxicity.
B. Discuss contraception with the client: There is no indication in the scenario that contraception counseling is an immediate priority or concern for this client at this time.
C. Set up a dietary consult for a low-sodium diet: Low-sodium diets can increase lithium reabsorption, worsening lithium toxicity. In fact, the client has hyponatremia (Na+ 131) already, so a low-sodium diet is contraindicated.
D. Educate the client about the need for hemodialysis: While hemodialysis may be required in severe lithium toxicity, this decision should be made by the provider. The nurse should monitor and report symptoms but not initiate education about dialysis unless prescribed.
E. Administer prochlorperazine: This is appropriate PRN medication for nausea and vomiting, which are symptoms of lithium toxicity and are present in this client.
F. Withhold next dose of lithium: The client’s current lithium level (2.2 mEq/L) is above the toxic range (>2.0 mEq/L). Continuing lithium could worsen toxicity, so the nurse should withhold the next dose and notify the provider.

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Correct Answer is D

Explanation

A. Heat intolerance is incorrect. Myxedema, which is a severe form of hypothyroidism, is typically associated with cold intolerance rather than heat intolerance. Clients with hypothyroidism often feel cold even in warm environments.
B. Diarrhea is incorrect. Clients with myxedema are more likely to experience constipation due to the slowed metabolic processes associated with hypothyroidism.
C. Tachycardia is incorrect. Myxedema is associated with bradycardia (slow heart rate), not tachycardia (fast heart rate). Hypothyroidism can slow down the body's overall processes, including heart rate.
D. Facial edema is correct. Facial edema (or puffiness) is a common sign of myxedema, which results from the accumulation of mucopolysaccharides in the tissues due to severe hypothyroidism. This can cause swelling, especially in the face, around the eyes, and the hands.

A. Intention tremors B. Hyperpigmentation C. Purple striations D. Hirsutism

Correct Answer is B

Explanation

A. Intention tremors are not associated with Addison's disease. They are typically seen in neurological conditions such as multiple sclerosis or cerebellar disorders.
B. Hyperpigmentation is a classic and expected finding in clients with Addison's disease, especially in primary adrenal insufficiency. It results from increased secretion of adrenocorticotropic hormone (ACTH), which stimulates melanocytes to produce more melanin, leading to darkening of the skin, particularly in areas exposed to friction such as elbows, knuckles, and mucous membranes.
C. Purple striations are more commonly seen in Cushing's syndrome, which involves excessive cortisol, the opposite of Addison’s disease (which involves cortisol deficiency).
D. Hirsutism (excessive hair growth) is also more characteristic of Cushing’s syndrome, due to increased androgen levels. It is not a typical finding in Addison’s disease.

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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.)

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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.)