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","C","D","E"]

Explanation

Choice A reason: Personality traits are enduring and can be resistant to change, making treatment challenging.

Choice B reason: This statement is not accurate; clients with personality disorders may not always be receptive to treatment.

Choice C reason: Slow progress and clients discontinuing treatment are common barriers in treating personality disorders.

Choice D reason: Clients may not recognize the need for change, which can hinder the therapeutic process.

Choice E reason: Clients may identify with their personality traits, even if they are maladaptive, and may resist changing them.

A. Projection. B. Displacement. C. Rationalization. D. Denial.

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

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Correct Answer is A

Explanation

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