A physician orders Lithium 1.2 grams/day in three divided doses PO for a client with bipolar disorder. The medication is supplied as 300 mg/5 mL. How much will the nurse administer per dose?

(Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

a. You are safe now.

Explanation of Choices

Choice A Reason: You Are Safe Now

This statement is the most appropriate because it immediately addresses the client’s need for safety and reassurance. Victims of sexual assault often experience intense fear and anxiety. By reassuring the client that they are now in a safe environment, the nurse helps to stabilize the client’s emotional state and begins to build trust. This statement is crucial in creating a sense of security, which is the first step in providing effective care and support.

Choice B Reason: I’ll Call Your Spouse

While involving a support person can be beneficial, this statement does not address the client’s immediate emotional needs. The priority at this moment is to ensure the client feels safe and supported. Once the client is reassured and stabilized, the nurse can then discuss involving family members or other support persons. Immediate focus should be on the client’s safety and emotional well-being.

Choice C Reason: We’ll Have to Take Photographs of These Wounds

Taking photographs for forensic evidence is an important part of the medical and legal process following a sexual assault. However, this statement is not therapeutic and does not address the client’s immediate emotional needs. Discussing forensic procedures should come after the client feels safe and supported. The nurse should first focus on providing emotional reassurance before moving on to procedural details.

Choice D Reason: The Police Will Want to Interview You

Informing the client about the need for a police interview is necessary, but it is not the priority therapeutic statement at this moment. The client is likely already overwhelmed and distressed. The nurse should first provide reassurance and emotional support before discussing legal procedures. Ensuring the client feels safe and supported is essential before introducing additional stressors.

The correct answer is c. Be consistent in staff limit setting.

Choice A Reason: Provide Positive Reinforcement for Acting-Out Behavior

Providing positive reinforcement for acting-out behavior is counterproductive, especially for clients with antisocial personality disorder (ASPD). Positive reinforcement would encourage the continuation of manipulative and disruptive behaviors, which are characteristic of ASPD. Instead, interventions should focus on promoting positive behaviors and discouraging negative ones.

Choice B Reason: Discourage the Client from Discussing Feelings of Fear and Inferiority

Discouraging clients from discussing their feelings is not a therapeutic approach. Clients with ASPD may have underlying issues that contribute to their behavior, and discussing these feelings can be an important part of therapy. Open communication can help in understanding the root causes of their behavior and developing effective treatment plans.

Choice C Reason: Be Consistent in Staff Limit Setting

Consistency in staff limit setting is crucial when dealing with clients with ASPD. These individuals often test boundaries and manipulate situations to their advantage. Consistent limit setting helps establish clear expectations and consequences, which can reduce manipulative behaviors and promote a more structured environment4. This approach helps clients understand that their actions have predictable outcomes, which is essential for behavior modification.

Choice D Reason: Ignore, Rather than Confront Inappropriate Behavior

Ignoring inappropriate behavior can lead to an escalation of such behaviors. Clients with ASPD may interpret this as a lack of consequences, reinforcing their manipulative actions. Confronting inappropriate behavior in a consistent and structured manner is necessary to address and modify these behaviors effectively.