A nurse is caring for a client who has an extremely elevated lithium level. Which of the following actions should the nurse take?

Prepare for gastric lavage.

Hold the medication and assess for early manifestations of toxicity.

Check the client's medication record to assess whether the client has been refusing her lithium.

Administer the morning dose of lithium.

Answer and Explanation

The Correct Answer is B

Choice A reason: Gastric lavage is typically not the first-line treatment for lithium toxicity due to the risk of aspiration and potential complications. It is usually reserved for cases where the ingestion was recent and massive.

Choice B reason: When a client presents with an extremely elevated lithium level, it is crucial to hold further doses to prevent exacerbation of toxicity. The nurse should monitor for early signs of toxicity, which include gastrointestinal symptoms like nausea, vomiting, diarrhea, and neurological symptoms such as tremors, confusion, and ataxia. The normal therapeutic range for lithium is 0.6 to 1.2 mmol/L, and levels above 1.5 mmol/L are considered toxic.

Choice C reason: While it is important to review the medication record, the immediate concern with an extremely elevated lithium level is addressing the toxicity. Checking the medication record can be part of the assessment process but is not the priority action.

Choice D reason: Administering the morning dose of lithium could worsen the client's condition by increasing the lithium level further, which is already extremely elevated. This could lead to severe toxicity or even fatal consequences.

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Correct Answer is ["B","D"]

Explanation

Choice A reason: Having two nurses present at all times may not be necessary and could be overwhelming for the client, making them feel less in control.

Choice B reason: Continuous assessment of the client's anxiety level is important to ensure that the nurse can respond to the client's needs and maintain a sense of safety.

Choice C reason: While promoting independence is good, the client may need assistance, and providing it can be part of creating a safe environment.

Choice D reason: Asking for permission is crucial as it respects the client's autonomy and helps them feel in control of their body, which is essential for someone who has experienced abuse.

Choice E reason: Having security present outside the room may be excessive and could contribute to a feeling of being guarded or watched, which may not be conducive to feeling safe and secure.

A. Talk the client through tasks one step at a time. B. Assign the same caregivers daily. C. Provide a consistent daily activity schedule. D. Allow ample time for the client to perform activities.

Correct Answer is A

Explanation

Choice A reason: For a client with Alzheimer's disease, it is beneficial to talk them through tasks one step at a time to help maintain their cognitive function and independence for as long as possible. This approach can reduce confusion and frustration.

Choice B reason: While rotating caregivers might provide variety, it can be confusing for a client with Alzheimer's disease. Consistency in caregivers can help establish a routine and sense of familiarity, which is comforting and can reduce anxiety.

Choice C reason: A consistent daily activity schedule is crucial for clients with Alzheimer's disease. It helps to maintain a sense of normalcy and can reduce stress and confusion. Changing the schedule daily could lead to increased anxiety and disorientation.

Choice D reason: Allowing ample time for activities is important as rushing can cause stress and agitation in clients with Alzheimer's disease. They often require more time to process information and complete tasks due to cognitive impairments.

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A nurse is caring for a client who has an extremely elevated lithium level. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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