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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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

Explanation

Choice A reason: This statement reflects a justification of the spouse's behavior, which can enable the continuation of abuse.

Choice B reason: Providing money for drugs, even if to prevent theft, is enabling the substance abuse to continue.

Choice C reason: Encouraging rehab is not enabling; it is an attempt to address the problem.

Choice D reason: Calling in sick for the spouse to cover for their potential job loss due to substance abuse is an enabling behavior.

Choice E reason: This is a protective behavior. Both are healthy responses to dealing with a partner’s destructive behavior.

A. "Where do you keep your gun?" B. "Are you thinking about hurting yourself or someone else?" C. "Have you thought about how you would hurt yourself?" D. "Can you tell me your feelings about dying?" E. "Have you told your psychiatrist you feel like dying?"

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

Explanation

Choice A reason: While it’s important to assess access to lethal means, this question is too specific and assumes the client owns a gun. A more appropriate question might be, “Do you have access to any means to harm yourself?”

Choice B reason: Inquiring about thoughts of self-harm or harming others is a direct question that assesses suicidal ideation and intent, which is essential for determining immediate risk.

Choice C reason: Understanding if the client has specific plans for self-harm can help gauge the immediacy and seriousness of the suicide risk.

Choice D reason: Discussing feelings about dying can provide insight into the client's emotional state and potential risk for suicide.

Choice E reason: This question is important but it should not replace direct questions about the client’s current thoughts and feelings. It’s possible for a client to deny feelings of suicidality to their psychiatrist while still experiencing them.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Which statement(s) made by the spouse indicates that they are exhibiting enabling behaviors? Select all that apply.

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

Explanation

The nurse should frequently assess a client with a depressive disorder for lethality risk related to suicidal ideation. Which questions should the nurse include? (Select all that apply.)

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

Explanation

A nurse is working with clients diagnosed with personality disorders. Which techniques would be most important for the nurse to use to effectively deal with the frustration in providing care to this group of clients? Select all that apply.

The nurse is working with clients with personality disorders that are having problems with relationships and other parts of their life. Which barrier(s) is the nurse experiencing when working with this group of clients? Select all that apply.

A nurse at a college campus mental health counseling center is caring for a student who just failed an examination. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms?

The nurse is performing an assessment for a client brought in by a family member who states they think the client has dementia. When evaluating the assessment data, which finding indicates that the client may likely have delirium and not dementia?

Which is a psychosocial explanation for the development of personality disorders?

The nurse is providing education for a client to improve mental and emotional health and influence the client's response to illness. Which statement made by the client indicates that the education is effective? (Select all that apply.)

The nurse is working to develop a therapeutic nurse-client relationship with a client diagnosed with paranoid personality disorder. Which techniques will the nurse use to foster trust? Select all that apply.

The nurse is planning the care of a client with bipolar disorder and addiction to heroin who is in a rehabilitation facility. Which outcomes will the nurse assign in the immediate phase after withdrawal symptoms are over? (Select all that apply.)