A nurse is caring for a client who has borderline personality disorder (BPD). What should the nurse monitor in the client’s Medication Administration Record?

Choice D rationale:

Lithium toxicity is a serious and potentially life-threatening condition. It can occur when lithium levels in the blood become too high.

Blurred vision and nausea are common early symptoms of lithium toxicity.

Withholding the medication is the most important action the nurse can take to prevent further toxicity and potential harm to the client.

The nurse should immediately notify the healthcare provider of the client's symptoms and the decision to withhold the medication.

The healthcare provider will likely order a lithium level to be drawn to assess the severity of the toxicity.

Depending on the results of the lithium level, the healthcare provider may order other interventions, such as intravenous fluids or medications to lower the lithium level.

Choice A rationale:

Encouraging the client to rest with his eyes closed may provide some temporary relief from the blurred vision, but it does not address the underlying problem of lithium toxicity.

It is important for the nurse to take more decisive action to prevent further toxicity.

Choice B rationale:

Re-checking the client in 4 hours may delay necessary interventions and allow the lithium toxicity to worsen.

It is important for the nurse to take immediate action to protect the client's health.

Choice C rationale:

Administering the next dose of lithium as prescribed would further increase the lithium level in the blood and could lead to more severe toxicity.

This is not a safe or appropriate action for the nurse to take in this situation.

The rationale for Choice A:

Limiting time for rituals to 30 minutes each day may not be effective and could potentially increase anxiety. Individuals with OCD often feel a strong compulsion to perform their rituals, and abruptly restricting their ability to do so can heighten distress and lead to increased attempts to engage in the rituals, even in a covert manner. This can create a cycle of anxiety and frustration.

Gradual exposure and response prevention (ERP) therapy is a more effective approach to reducing ritualistic behaviors. It involves gradually exposing the individual to anxiety-provoking stimuli while helping them to resist engaging in their compulsions. This process is done in a controlled and supportive environment, to help the individual learn to manage their anxiety and reduce their reliance on rituals.

Rationale for Choice B:

Providing a stimulating environment is not generally recommended for individuals with OCD. Excessive stimulation can exacerbate anxiety and trigger compulsive behaviors. A calmer and more structured environment is often more beneficial.

Individuals with OCD often thrive in environments that provide predictability and a sense of control. A structured schedule can help to reduce uncertainty and create a sense of order, which can in turn help to reduce anxiety and the urge to engage in compulsive behaviors. Rationale for Choice C:

Negative reinforcement is not an appropriate or effective intervention for OCD. It involves punishing or removing a desired stimulus in response to a behavior, with the aim of decreasing the likelihood of that behavior occurring again. However, this approach can be counterproductive in OCD, as it can increase anxiety and make the individual more likely to engage in their rituals in order to avoid the negative consequences.

Positive reinforcement, such as praise and encouragement, is more effective in promoting desired behaviors. This approach focuses on rewarding the individual for making progress in reducing their ritualistic behaviors, which can help to increase motivation and create a more positive and supportive environment for change.

Rationale for Choice D:

Providing a structured schedule of activities can be a very effective intervention for OCD. It can help to reduce anxiety, provide a sense of control, and minimize the time available for engaging in compulsive rituals.

A structured schedule can include a variety of activities, such as:

Mealtimes

Personal hygiene routines

Work or school activities

Leisure activities

Relaxation exercises

Social interactions

The schedule should be tailored to the individual's specific needs and preferences. It is important to ensure that the activities are enjoyable and meaningful to the individual, as this will increase their motivation to participate.

The nurse can work with the individual to develop a schedule that is realistic and achievable. The schedule should be reviewed and adjusted regularly as the individual makes progress.