A nurse is caring for a client at a follow-up visit who has been taking lithium therapy for bipolar disorder.
Which of the following findings should indicate to the nurse that the client is experiencing lithium toxicity?

Hypoglycemia.

Excess salivation.

Urinary retention.

Dysrhythmia.

Answer and Explanation

The Correct Answer is D

Dysrhythmia is an abnormal heart rhythm that can be a sign of severe lithium toxicity.

Lithium toxicity can occur when a person takes too much lithium, a mood- stabilizing medication used to treat bipolar disorder and major depressive disorder.

Choice A is wrong because hypoglycemia is not a symptom of lithium toxicity. Hypoglycemia is low blood sugar that can cause symptoms such as shakiness, sweating, hunger, and confusion.

Choice B is wrong because excess salivation is not a symptom of lithium toxicity. Excess salivation can be caused by various factors, such as infections, medications, or nerve damage.

Choice C is wrong because urinary retention is not a symptom of lithium toxicity. Urinary retention is the inability to empty the bladder completely, which can cause pain, discomfort, and infection. Lithium toxicity can actually cause increased urine output, not decreased.

Normal ranges for blood lithium levels are 0.6 to 1.2 mEq/L for maintenance therapy and 0.8 to 1.5 mEq/L for acute therapy. Levels above 1.5 mEq/L can cause mild to moderate toxicity, and levels above 2.0 mEq/L can cause severe toxicity. Levels above 3.0 mEq/L are considered a medical emergency.

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Correct Answer is B

Explanation

“I will not play soccer until my doctor tells me I can.” This statement indicates that the client understands the risk of splenic rupture due to splenomegaly and the need to avoid contact sports until the spleen returns to normal size.

Choice A is wrong because antibiotics are not effective for infectious mononucleosis, which is caused by a virus.

Choice C is wrong because varicella booster is not related to infectious mononucleosis and there is no evidence that the client needs it.

Choice D is wrong because jaundice (yellowing of the eyes and skin) is not a common manifestation of infectious mononucleosis and may indicate another condition such as hepatitis.

Normal ranges for spleen size are 7 to 14 cm in length and 3 to 4 cm in thickness.

A. Leg cramps. B. Ptyalism. C. Blurred vision. D. Melasma.

Correct Answer is C

Explanation

This can be a sign of preeclampsia, a serious complication of pregnancy that causes high blood pressure and proteinuria.

The nurse should report this finding to the provider and monitor the client’s blood pressure, urine protein, and reflexes.

Choice A is wrong because leg cramps are a common discomfort during pregnancy and are not usually a sign of a complication.

Choice B is wrong because ptyalism, or excessive salivation, is a normal physiological change during pregnancy and does not indicate a problem.

Choice D is wrong because melasma, or darkening of the skin on the face, is also a normal physiological change during pregnancy and does not pose a risk to the mother or the fetus.

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A nurse is caring for a client at a follow-up visit who has been taking lithium therapy for bipolar disorder. Which of the following findings should indicate to the nurse that the client is experiencing lithium toxicity?

Nursing Test Bank

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Correct Answer is B

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A nurse is caring for a client at a follow-up visit who has been taking lithium therapy for bipolar disorder.
Which of the following findings should indicate to the nurse that the client is experiencing lithium toxicity?