A nurse is caring for a client in a clinic.

Exhibits

For each body system below, click to specify the adverse effect that the nurse should include in the teaching. Choose the most likely response for the dropdown(s) in the table below by choosing from the lists of options.

Body System	Common Adverse Effects
Head, eyes, ears, nose, and throat (HEENT)	dropdown
Cardiovascular	dropdown
Genitourinary	dropdown
Gastrointestinal	dropdown

Note: Each drop down must have 1 response selected.

A. Irrigate the wound with a low-pressure flow of solution: Low-pressure irrigation (typically using a 30–60 mL syringe with an 18-gauge catheter) effectively removes debris and reduces tissue trauma, promoting wound healing while preventing the spread of bacteria deeper into the tissue.
B. Cleanse the insertion site of the drain using a circular motion toward the center: Wound cleansing should proceed from the center outward, not toward the center, to avoid introducing contaminants into the wound or insertion site.
C. Cleanse the wound starting at the bottom and moving upward: Wound cleansing should always be done from the cleanest to dirtiest area starting at the top (incision site) and moving downward, not the reverse, to prevent contamination.
D. Irrigate the wound using a 10 mL syringe: A 10 mL syringe does not generate sufficient volume or pressure for effective wound irrigation. Larger syringes (30–60 mL) are preferred to provide adequate flow for proper cleansing.

A. “It will take at least a week before this medication reaches a therapeutic level.” Lithium reaches therapeutic plasma levels in approximately 5–7 days. Clients should be informed that mood stabilization and symptom improvement may not be immediate and may take up to 2–3 weeks.
B. “You will be placed on a low-sodium diet while taking this medication.” This is contraindicated because low sodium intake can increase lithium reabsorption by the kidneys, significantly raising the risk of lithium toxicity. A stable and adequate sodium intake is essential.
C. “This medication can cause weight gain” Weight gain is a common side effect of lithium, often related to changes in metabolism, appetite increase, and fluid retention. Clients should be monitored and provided with dietary and activity guidance.
D. “Blurred vision is an expected adverse effect of this medication.” Blurred vision is not an expected effect of lithium and may indicate toxicity or another medical condition. Any visual changes should prompt immediate evaluation rather than be considered routine.
E. “This medication can cause nausea and drowsiness.” These are common early side effects of lithium, especially during initiation. Taking the medication with food and adjusting administration times may help reduce gastrointestinal upset and sedation.