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","C","D"]

Explanation

Choice A reason: This statement could be misleading and potentially harmful as it may encourage unhealthy weight goals. Optimal health is not necessarily correlated with being at or below a certain weight.

Choice B reason: Developing coping strategies to handle emotional issues is a key preventative measure against eating disorders, as it helps individuals manage stress without resorting to disordered eating behaviors.

Choice C reason: Encouraging realistic ideas about body shape and size and avoiding comparisons to an "ideal" can prevent the development of negative body image, which is often associated with eating disorders.

Choice D reason: Helping adolescents find achievable outcomes to increase self-esteem can reduce the risk of eating disorders, as low self-esteem is a known risk factor.

A. Drinks alcohol to excess 3 days a week. B. States that they hang on to bad relationships due to fear of being alone. C. Went back to college to complete a degree in nursing. D. Divorced 3 times with tumultuous relationships with spouses. E. Several trusting relationships with friends.

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

Explanation

Choice A reason: Drinking alcohol to excess is a behavior that can be influenced by growing up in a home with alcoholic parents, as it may become a learned coping mechanism.

Choice B reason: Hanging on to bad relationships due to fear of being alone can be a behavior stemming from the instability and insecurity experienced in a home with alcoholic parents.

Choice C reason: Returning to college to complete a degree does not directly correlate with the influence of growing up in a home with alcoholic parents and is more indicative of personal ambition and goals.

Choice D reason: Having multiple divorces with tumultuous relationships could be related to the dysfunctional relationship dynamics observed in a home with alcoholic parents.

Choice E reason: Forming several trusting relationships with friends does not necessarily correlate with growing up in a home with alcoholic parents and is generally a positive social behavior.

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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

The nurse is providing a high-school prevention program for adolescents and parents about eating disorders. Which important preventative measures will the nurse educate the group regarding? (Select all that apply.)

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

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Explanation

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