How should the nurse document the behavior of a patient with mental illness?

A. Transport victim to hospital: While transport to the hospital is necessary, it is not the immediate priority when the victim is still on fire.

B. Stop, drop, and roll: The first action for someone whose clothing is on fire is to stop, drop, and roll to extinguish the flames and prevent further burns.

C. Cover victim with clean cloth or sheet: Covering with a clean cloth is important after the flames have been extinguished but not the first step when the victim is still burning.

D. Remove all nonadherent clothing and jewelry: Removing clothing and jewelry should be done after the flames are extinguished and initial care has been administered.

A. Take her blood pressure twice a day to check for hypertension. Lithium does not typically cause hypertension. Monitoring blood pressure is not a primary concern for patients on lithium.
B. Have her drug blood level checked every month. Regular monitoring of lithium blood levels is crucial to ensure therapeutic levels and avoid toxicity. Lithium has a narrow therapeutic window, and frequent monitoring helps in adjusting the dose to maintain safe and effective levels.
C. Avoid aged cheese and red wine. This advice is relevant for patients taking MAOIs, not lithium. There is no need for patients on lithium to avoid these foods specifically.
D. Examine her skin closely for eruptions. While skin eruptions can be a side effect of some medications, it is not a primary concern for patients on lithium. The focus should be on monitoring for signs of lithium toxicity and other common side effects like tremors, thyroid dysfunction, and renal impairment.