A nurse is reviewing discharge instructions with a client who has bipolar disorder and is taking lithium. Which of the following manifestations should the nurse include as an indication of mild toxicity?

Muscle weakness.

Constipation.

Urinary retention.

Hyperactivity.

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Muscle weakness is a manifestation of mild lithium toxicity. Lithium toxicity can occur at therapeutic levels, so clients should be monitored for adverse effects.
Choice B rationale:
Constipation is not typically associated with lithium toxicity. Diarrhea, not constipation, is a symptom of lithium toxicity.
Choice C rationale:
Urinary retention is not a typical symptom of lithium toxicity. Increased urination and thirst are common side effects of lithium.
Choice D rationale:
Hyperactivity is not a typical symptom of lithium toxicity. Lithium is used to manage bipolar disorder and can help reduce hyperactivity.

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Correct Answer is C

Explanation

Choice A rationale:

Delusional disorder is characterized by the presence of one or more delusions for a month or longer, which could be plausible but are not real. This is not the case here.

Choice B rationale:

Anhedonia refers to the inability to experience pleasure, a common symptom in many mental disorders, including depression. It does not apply to this situation.

Choice C rationale:

Associative looseness, or loose associations, is a thought disorder characterized by speech in which ideas shift from one subject to another that is unrelated or minimally related. The client’s statement is an example of this.

Choice D rationale:

Hallucinations are sensory experiences that occur in the absence of actual stimulation. The client’s statement is not a hallucination, but a disorganized thought process.

A. "Do you really think it is ok not to bathe? What is going on with you?". B. "It is now time for you to bathe. Do you want to wear the red or green shirt?". C. "This is it! You are getting a bath! There are three of us here to bathe you!". D. "I'm going to ignore your lack of self-care because it is an aspect of the disorder.”.

Correct Answer is B

Explanation

Choice A rationale:

This statement is confrontational and may make the client defensive.

Choice B rationale:

This statement provides the client with a choice, promoting autonomy and encouraging self-care.

Choice C rationale:

This statement is forceful and does not respect the client’s autonomy.

Choice D rationale:

Ignoring the client’s lack of self-care does not address the issue and could potentially harm the client.

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A nurse is reviewing discharge instructions with a client who has bipolar disorder and is taking lithium. Which of the following manifestations should the nurse include as an indication of mild toxicity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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