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: Coping patterns can influence an individual's ability to handle stress and may contribute to suicide risk if they are maladaptive.

Choice B reason: Alcohol use can increase impulsivity and lower inhibitions, potentially increasing the risk of suicide.

Choice C reason: Socioeconomic status can impact access to resources and support, which may affect an individual's suicide risk.

Choice D reason: Support systems can provide emotional support and connection, which are protective factors against suicide.

Choice E reason: Identifying suicide risk is essential in assessing the immediate danger and the need for interventions.

A. "The client feels like they won't be believed since there was alcohol involved during the date." B. "Did you see that outfit that the client is wearing? What did they expect?" C. "We need to offer the client emotional support, especially when obtaining specimens." D. "When the client said 'stop,' that was enough for the perpetrator to get up and walk away."

Correct Answer is B

Explanation

Choice A reason: While it's important to understand the client's concerns about being believed, this statement does not require immediate correction as it reflects a common worry among survivors of sexual assault.

Choice B reason: This statement is victim-blaming and perpetuates harmful stereotypes. It requires immediate correction to ensure the client receives compassionate and nonjudgmental care.

Choice C reason: Offering emotional support is an appropriate and necessary part of care for a survivor of sexual assault.

Choice D reason: Acknowledging the client's autonomy and the perpetrator's responsibility to respect consent is correct and does not require correction.

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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

A nurse is assessing risk factors for suicide. Which of the following should the nurse consider? Select all that apply.

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

Explanation

The nurse is working with another nurse in the emergency department (ED) when a client comes in stating they have been raped during a date. Which statement made by the other nurse privately requires immediate correction?

Correct Answer is B

Explanation

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