A nurse is collecting data from a client who is taking lithium. Which of the following findings should the nurse identify as early manifestations of lithium toxicity? (Select all that apply.)

Incoordination

Polyuria

Nausea

Convulsions

Confusion

Answer and Explanation

Correct Answer : A,C,E

A.   Incoordination, such as clumsiness or difficulty walking, can be an early sign of lithium toxicity. It reflects the neurological effects of elevated lithium levels on motor coordination.
B.   Polyuria (excessive urination) is a common late symptom of lithium toxicity. Lithium interferes with the kidney's ability to concentrate urine, leading to increased urine output.
C.   Nausea is a gastrointestinal symptom that can occur in the early stages of lithium toxicity. It is often accompanied by other gastrointestinal disturbances such as vomiting and diarrhea.
D.   Convulsions (seizures) are not typically considered early manifestations of lithium toxicity but rather indicate severe toxicity. Seizures can occur at higher levels of lithium toxicity and require immediate medical intervention.
E.   Confusion is another early sign of lithium toxicity. It reflects the impact of elevated lithium levels on the central nervous system, leading to cognitive impairment and altered mental status.

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Correct Answer is A

Explanation

A. One of the nurse's responsibilities during the informed consent process is to witness the client signing the consent form. This ensures that the client voluntarily agrees to undergo ECT after receiving adequate information about the procedure, its risks, benefits, and alternatives. By witnessing the signature, the nurse confirms that the client's consent is documented appropriately and legally.
B. Nurses may provide general information about ECT and its alternatives, but the detailed discussion about treatment options and their implications usually occurs during the consultation with the provider.
C. Determining if a client is competent to give consent is a legal determination typically made by a healthcare provider or a legal representative, not the nurse.
D. It is not the nurse's role to discuss the specific benefits of ECT, as these discussions are the responsibility of the healthcare provider leading the client's care.

A. Place the client in a room close to the nurses' station. B. Request a consult with recreational therapy. C. Lower the window shade in the client's room. D. Obtain a PRN prescription for a vest restraint.

Correct Answer is A

Explanation

A. This is a proactive measure to enhance supervision and quick response to any signs of agitation, wandering, or attempts to get out of bed without assistance. Being closer to the nurses' station allows for more frequent monitoring and timely intervention to prevent falls.
B. Recreational therapy can play a significant role in enhancing the client's physical and cognitive abilities through tailored activities. Activities such as balance exercises, supervised walks, or engaging in structured programs can help improve mobility and reduce the risk of falls.
C. Lowering the window shade can reduce distractions and provide a calmer environment for the client. Excessive light or glare can sometimes contribute to confusion or disorientation in individuals with dementia. A more subdued environment can potentially decrease agitation and wandering behaviors, indirectly lowering the risk of falls.

D. The use of physical restraints, such as vest restraints, is generally discouraged in clients with dementia due to the potential for physical and psychological harm. Restraints can increase agitation, anxiety, and risk of injury, and they do not address the underlying causes of falls. The focus should be on environmental modifications, supervision, and non-pharmacological interventions.

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A nurse is collecting data from a client who is taking lithium. Which of the following findings should the nurse identify as early manifestations of lithium toxicity? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who is scheduled to receive electroconvulsive therapy (ECT). Which of the following is the nurse's role during the informed consent process?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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