A nurse is reinforcing teaching with a client who is to start taking lithium for bipolar disorder. Which of the following instructions should the nurse include?
Choose foods that are low in sodium.
Expect to lose weight while taking this medication.
Limit fluid intake of 1 liter per day.
Take lithium with meals or a glass of milk.
The Correct Answer is D
Choice A reason: Clients should maintain consistent sodium intake, not restrict it. Low sodium can increase lithium toxicity.
Choice B reason: Weight gain, not weight loss, is a common side effect of lithium.
Choice C reason: Fluid intake should not be restricted. Adequate hydration is essential to prevent lithium toxicity.
Choice D reason: Taking lithium with meals or milk reduces gastrointestinal irritation, making this the correct teaching point.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Promising secrecy is inappropriate because nurses are mandated reporters. They are legally and ethically obligated to report suspected child abuse. Making such a promise undermines trust when disclosure becomes necessary.
Choice B reason: Labeling the family as "bad" is judgmental and non-therapeutic. It risks alienating the child and does not provide supportive reassurance.
Choice C reason: Telling the child that it is not their fault is therapeutic and supportive. Children often internalize blame for abuse, so this statement helps reduce guilt and shame while validating their experience.
Choice D reason: Discussing the abuse directly with family members can place the child at further risk and is inappropriate. The nurse must follow mandated reporting procedures rather than confronting the family.
Correct Answer is A
Explanation
Choice A reason: Asking if the client has a plan to commit suicide is the priority intervention. It directly assesses the level of risk and helps determine the immediacy of danger. Suicide risk assessment is essential in borderline personality disorder, where impulsivity and self-harm are common.
Choice B reason: Assuming manipulation dismisses the seriousness of suicidal ideation. Even if manipulation is suspected, all suicidal statements must be taken seriously to ensure safety.
Choice C reason: Allowing the client to rest does not address the risk of suicide. Safety assessment must occur before any other intervention.
Choice D reason: Notifying family may be supportive but is not the immediate priority. The nurse must first assess the client’s risk and ensure safety before involving others.
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