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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Bulimia Nervosa often involves behaviors such as excessive laxative use, which can lead to severe electrolyte imbalances, potentially causing unconsciousness.
Choice B reason: While a sudden cardiac event is possible, it is less likely to be directly related to the history of Bulimia Nervosa and laxative use.
Choice C reason: There is no indication that an accidental fall occurred, and it would not be directly related to the history of laxative use.
Choice D reason: Without further information, it is speculative to attribute the unconsciousness to a reaction to another medication.
Correct Answer is C
Explanation
Choice A reason: Acrophobia is the fear of heights, which is not indicated by the client's fear of being outdoors alone.
Choice B reason: Xenophobia is the fear of strangers or foreigners, which does not align with the client's described fear.
Choice C reason: Agoraphobia is the fear of open spaces or being in crowded, public places like markets. It also includes the fear of leaving a safe place, such as home, which aligns with the client's symptoms.
Choice D reason: Mysophobia is the fear of germs, which is not related to the fear of being outdoors alone.
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