A nurse is caring for a client who is taking lithium and reports experiencing lethargy, muscle weakness, and blurred vision. Which of the following responses should the nurse make?
"These symptoms will improve over time."
"You will need to have your blood drawn."
"You should decrease your intake of sodium."
"Continue the medication as prescribed."
The Correct Answer is B
Choice A reason: Telling the client that the symptoms will improve over time without further assessment could be misleading. These symptoms could indicate lithium toxicity, which requires immediate medical attention.
Choice B reason: Lethargy, muscle weakness, and blurred vision can be signs of lithium toxicity. The nurse should recommend blood tests to check lithium levels and kidney function to rule out toxicity.
Choice C reason: Decreasing sodium intake is not recommended without a healthcare provider's advice, as sodium levels can affect lithium levels in the body. Sudden changes in sodium intake should be avoided unless directed by a healthcare provider.
Choice D reason: Continuing the medication as prescribed without addressing the symptoms could be dangerous. The symptoms reported by the client need to be evaluated to ensure they are not due to lithium toxicity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: While sharing personal experiences can sometimes help in connecting with the grieving individual, it may also shift the focus away from the partner's feelings to the nurse's own experiences. It's important to keep the conversation centered on the partner's emotions and support needs.
Choice B reason: This response acknowledges the partner's feelings without judgment and opens the door for further conversation. It shows empathy and understanding, which are crucial in providing emotional support to someone who is grieving.
Choice C reason: Suggesting a grief counselor is a practical step, but it might be perceived as dismissive if offered too quickly. It's essential to first establish a supportive dialogue and understand the partner's readiness to seek additional help.
Choice D reason: Telling someone they shouldn't feel guilty can invalidate their feelings. Guilt is a common emotion in the grieving process, and it's important to acknowledge it and provide a safe space for the individual to express their feelings.
Correct Answer is C
Explanation
Choice A reason: Notifying law enforcement within 2 hours if the person cannot be found is important, but immediate action is usually recommended in such cases. The sooner the authorities are alerted, the better the chances of locating the individual safely.
Choice B reason: Giving the most recent photo to the police is a proactive step in case the person goes missing. It can help law enforcement quickly disseminate the information and aid in the search. However, this is a reactive measure rather than a preventive one.
Choice C reason: Placing a sliding bolt lock just above the doorknob can prevent the individual from wandering, which is a common and dangerous issue in people with advanced Alzheimer's disease. This measure helps ensure the person's safety by preventing unsupervised exits from the home.
Choice D reason: Ensuring the bedroom is dark while the person is sleeping may not be advisable. Adequate night lighting is important for preventing falls if the person needs to get up during the night. A completely dark room can increase the risk of injury.
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