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A nurse is caring for a client who has bipolar disorder.

Exhibits

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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Regression is reverting to earlier developmental behaviors (e.g., thumb-sucking under stress). The patient is not showing childlike behaviors.

B. Projection involves attributing one’s own unacceptable feelings to others. The patient is not blaming others for symptoms.

C. Denial is refusing to acknowledge a painful reality. Despite clear symptoms and diagnostic testing, the patient minimizes illness by attributing it to "just a stubborn chest cold."

D. Displacement is redirecting emotions onto a safer target (e.g., yelling at spouse instead of boss). Not evident here.

A. "Unfortunately, delirium is a progressively disabling disorder." B. "The confusion will probably get better as we treat the infection. C. The health care provider is the best person to answer your question." D. "I will be glad to contact the chaplain to talk with you."

Correct Answer is B

Explanation

A. Delirium is usually acute and reversible, especially when caused by an underlying condition like a UTI.

B. Delirium in elderly patients is often secondary to an acute illness such as a urinary tract infection. Treatment of the underlying cause typically resolves the confusion, so this statement provides accurate and reassuring information to the family.

C. While the provider can give a formal prognosis, the nurse can provide evidence-based, general information about delirium recovery.

D. While supportive, this does not address the family’s question about recovery.

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A nurse is caring for a client who has bipolar disorder. Exhibits Which of the following assessment findings require immediate follow- up? (Select all that apply.)

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A nurse is caring for a client who has bipolar disorder.

Exhibits

Which of the following assessment findings require immediate follow- up? (Select all that apply.)