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 D
Explanation
A. Concerns about returning to school reflect normal adjustment issues and do not indicate immediate danger.
B. Expressing happiness about being home is a positive statement and does not require urgent intervention.
C. Hypervigilance and startle responses are common symptoms of PTSD and should be monitored but are not immediately life-threatening.
D. Expressions of survivor’s guilt or thoughts questioning why one survived while others did not can indicate severe emotional distress and possible risk for self-harm or suicidal ideation. This statement requires immediate assessment and intervention by the nurse.
Correct Answer is B
Explanation
A. Referring the patient to a minister avoids the nurse’s responsibility to provide immediate therapeutic support.
B. This response reflects the patient’s feelings and encourages further expression, which is therapeutic in depression.
C. Asking “why” can feel judgmental and place the patient on the defensive, which is non-therapeutic.
D. Giving false reassurance or imposing religious beliefs does not address the patient’s feelings and may shut down communication.
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