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 A

Explanation

Choice A reason: Projection involves attributing one's own unacceptable feelings or thoughts to others, which may be the case when the student blames the teacher for their own failure.

Choice B reason: Displacement involves shifting negative feelings to a less threatening object or person, which is not clearly indicated in this scenario.

Choice C reason: Rationalization involves justifying behaviors or feelings with logical reasons, often avoiding the true reasons, which does not seem to apply here.

Choice D reason: Denial involves refusing to accept reality or facts, which is not the defense mechanism being demonstrated by the student's behavior of blaming the teacher.

A. Increase foods high in fiber. B. Use sunscreen when outdoors. C. Use laxatives as needed. D. Develop an exercise program. E. Take double the dose at the next scheduled time for missed doses. F. Drink plenty of fruit juice.

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

Explanation

Choice A reason: Increasing dietary fiber can help manage constipation, which is a common side effect of antipsychotic medications. The normal range for dietary fiber intake in adults is 25 to 30 grams per day from food, not supplements.

Choice B reason: Antipsychotic medications can increase photosensitivity, making the skin more susceptible to sunburn. Using sunscreen can help protect the skin when outdoors.

Choice C reason: While laxatives can be used to manage constipation, they should be used sparingly and only as needed to avoid dependence and potential electrolyte imbalances.

Choice D reason: Regular physical activity can help counteract weight gain, another potential side effect of antipsychotic medications. It's recommended to engage in at least 150 minutes of moderate-intensity exercise per week.

Choice E reason: Doubling the dose at the next scheduled time for missed doses is not recommended as it can lead to an overdose and exacerbate side effects.

Choice F reason: Drinking plenty of fluids, including fruit juice, can help prevent dehydration. However, it's important to monitor sugar intake from fruit juices due to the risk of weight gain.

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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 A

Explanation

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

Explanation

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