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 D

Explanation

Choice A reason: This statement does not necessarily suggest a somatoform disorder, as it expresses hope for a medical diagnosis.

Choice B reason: Mentioning overexertion could be a logical explanation for pain and does not directly indicate a somatoform disorder.

Choice C reason: Expressing difficulty with life changes does not specifically suggest a somatoform disorder, which is characterized by physical symptoms without a medical cause.

Choice D reason: This statement suggests that the pain may be linked to psychological factors, such as stress from losing a job, which is characteristic of a somatoform disorder.

A. Blunt affect B. Poor judgments C. Delusions D. Anhedonia E. Hallucinations

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

Explanation

Choice A reason: Blunt affect is a negative symptom of schizophrenia, characterized by a significant reduction in the expression of emotions.

Choice B reason: Poor judgments are not specifically categorized as negative symptoms; they can be a result of cognitive deficits associated with schizophrenia.

Choice C reason: Delusions are considered positive symptoms of schizophrenia, involving false beliefs maintained despite evidence to the contrary.

Choice D reason: Anhedonia, the inability to experience pleasure, is a negative symptom of schizophrenia, reflecting a diminished interest or pleasure in all or almost all activities.

Choice E reason: Hallucinations are considered positive symptoms of schizophrenia, involving perceiving things that are not present.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Explanation

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