A nurse reviews the provider prescriptions and reassesses the client.

Exhibits

The nurse is continuing to care for the client. Which of the following actions should the nurse take? Select all that apply.

A. Discuss the client's preferences for determining a repositioning schedule. While it's important to consider the client's comfort, repositioning must follow clinical guidelines (typically every 2 hours) to prevent pressure injuries, especially in clients with limited mobility post-stroke.
B. Raise the side rails on both sides of the client's bed during repositioning. Raising both side rails can be considered a form of restraint if not medically justified. Only one rail should be raised for safety and support unless otherwise indicated by facility policy.
C. Reposition the client without the use of assistive devices. Repositioning a client post-stroke without proper equipment increases the risk of injury to both the client and the nurse. Assistive devices promote safety and proper body mechanics.
D. Evaluate the client's ability to help with repositioning. This is the first and most important step. Assessing the client’s physical capability and level of consciousness ensures that the nurse uses the appropriate technique and equipment for safe repositioning.

A. "Blurred vision is an expected adverse effect of this medication." Blurred vision is not a common or expected adverse effect of lithium. If this occurs, it may indicate toxicity or another underlying issue and should be reported. It is not part of routine education for expected side effects.
B. "This medication can cause weight gain." This is true. Weight gain is a known long-term adverse effect of lithium therapy and should be discussed with the client and family as part of monitoring and lifestyle considerations during treatment.
C. "This medication can cause nausea and drowsiness." These are common initial side effects when starting lithium and usually subside over time. Clients should be aware of these effects so they can differentiate between expected reactions and signs of toxicity.
D. "It will take at least a week before this medication reaches a therapeutic level." Correct. Lithium takes 7–14 days to reach therapeutic plasma levels, so clients may not experience symptom relief immediately. During this period, supportive care and safety monitoring are essential.
E. "You will be placed on a low-sodium diet while taking this medication." This is incorrect. Lithium has a narrow therapeutic index, and sodium levels affect lithium levels. A low-sodium diet can increase the risk of lithium toxicity, so clients should maintain a consistent sodium intake, not reduce it.