A nurse is caring for a client who has bipolar disorder.
Which of the following assessment findings require immediate follow- up? (Select all that apply.)
Blood pressure
Lithium level
Sodium level
WBC count
Thyroid-stimulating (TSH) level
BUN level
Levothyroxine dosage
Acetaminophen
Lithium dosage
Correct Answer : B,C,F,I
A. Blood pressure – Within normal range (115/76 mm Hg). No immediate concern.
B. Lithium level – 1.7 mEq/L is above the therapeutic range (0.8–1.2). Toxicity is likely, especially with the client’s symptoms (tremor, confusion, GI upset). Requires urgent follow-up.
C. Sodium level – 128 mEq/L indicates hyponatremia. Low sodium increases the risk for lithium toxicity because lithium and sodium compete for renal reabsorption.
D. WBC count – Within normal range (7,000/mm³).
E. TSH level – Mildly elevated (6). Suggests hypothyroidism (a side effect of lithium) but not immediately life-threatening. Requires follow-up, but not urgent.
F. BUN level –Elevated at 30 mg/dL (normal 10–20). Indicates impaired renal function, which reduces lithium clearance and increases toxicity risk.
G. Levothyroxine dosage – No immediate safety issue noted; managed long term.
H. Acetaminophen – Daily 325 mg is safe; not a concern.
I. Lithium dosage – Current dose (600 mg BID) is likely contributing to toxicity and must be reassessed immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Prickly skin sensations may occur with anxiety or substance use, not psychomotor agitation.
B. Slowed verbal responses indicate psychomotor retardation, not agitation.
C. Psychomotor agitation refers to increased, purposeless movement such as pacing, hand-wringing, or fidgeting.
D. Asking to repeat instructions indicates poor concentration, not specifically psychomotor agitation.
Correct Answer is C
Explanation
A. Giving medication against a patient’s wishes does not fulfill the standard of care; it violates patient autonomy.
B. Malpractice involves professional negligence resulting in harm, but here the issue is intentional violation of patient rights, not negligence.
C. Administering medication after a patient has explicitly refused is considered battery, which is intentional and unauthorized physical contact, even if harm does not occur.
D. Negligence is a failure to act reasonably or omission of care. This situation is an intentional act, making battery the correct legal term.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
