A nurse is reviewing laboratory results for a client and notes a serum lithium level of 1.6 mEq/L. Which of the following manifestations should the nurse expect the client to report?.

GI discomfort and poor coordination.

Lip smacking and tongue thrusting.

Blurred vision and jerking motor movements.

Fever and fluctuating blood pressure.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

A serum lithium level of 1.6 mEq/L is above the therapeutic range (0.6-1.2 mEq/L) and can cause symptoms such as GI discomfort and poor coordination.

Choice B rationale:

Lip smacking and tongue thrusting are not typically associated with lithium toxicity.

Choice C rationale:

While blurred vision can be a symptom of lithium toxicity, jerking motor movements are not typically associated with this condition.

Choice D rationale:

Fever and fluctuating blood pressure are not typically symptoms of lithium toxicity.

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Correct Answer is A

Explanation

Choice A rationale:

Weight gain is a common side effect of risperidone. Antipsychotic medications like risperidone often lead to weight gain.

Choice B rationale:

Bradycardia is not typically associated with risperidone. Risperidone can cause mild heart rate changes, but significant bradycardia is not common.

Choice C rationale:

Nightmares are not a typical side effect of risperidone. Sleep disturbances can occur, but they are not the most common side effect.

Choice D rationale:

Dependent edema is not a common side effect of risperidone.

A. Assign a staff member to stay with the client at all times. B. Lock the doors to the unit and secure windows so they cannot be opened. C. Remove any objects from the client's environment that could be used for self-harm. D. Provide the client with plastic eating utensils for meals.

Correct Answer is A

Explanation

Choice A rationale:
Assigning a staff member to stay with the client at all times is the priority action when a client declines to make a safety contract. This is because the immediate safety of the client is the primary concern in such situations.
Choice B rationale:
Locking the doors to the unit and securing windows so they cannot be opened might be considered a safety measure, but it is not the priority. The focus should be on direct supervision to ensure safety.
Choice C rationale:
Removing any objects from the client’s environment that could be used for self-harm is important, but it is not the priority. The immediate safety of the client through constant supervision is the priority.
Choice D rationale:
Providing the client with plastic eating utensils for meals is a safety measure, but it is not the priority. The immediate safety of the client through constant supervision is the priority.

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A nurse is reviewing laboratory results for a client and notes a serum lithium level of 1.6 mEq/L. Which of the following manifestations should the nurse expect the client to report?.

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