Medical History: Borderline personality disorder.

Alcohol use disorder.

History of suicidal ideation.

Medication Administration Record: Fluoxetine 20 mg PO daily.

Nurses' Notes: . 1500: Client admitted for evaluation and treatment following arrest for driving while under the influence of alcohol.

Client reports recent breakup of romantic relationship and subsequent job loss.

States, "I was too upset to go to work, and then they fired me. Like I needed that stress, too.”. 1700: Noted client has multiple cuts on arms and legs and there is a broken mirror with blood on it on the floor.

Client states, "I feel so alone.

There is no one that cares about me.”. For each potential nursing action, click to specify if the potential action is anticipated, nonessential, or contraindicated for the client.

Instruct the client to avoid foods with tyramine.

Apply wrist restraints.

Offer sympathy and attention to maladaptive behavior.

Encourage the client to talk about feelings prior to maladaptive behavior.

Maintain same staff members caring for the client.

Answer and Explanation

The Correct Answer is F

Choice A rationale:
Instructing the client to avoid foods with tyramine is not relevant in this case. Tyramine is associated with certain antidepressants known as MAOIs, but the client is taking Fluoxetine, which is an SSRI2.
Choice B rationale:
Applying wrist restraints might be necessary in extreme situations to ensure the client’s safety, but it should be a last resort and not the first response to self-harm.
Choice C rationale:
Offering sympathy and attention to maladaptive behavior could reinforce negative behaviors and is not recommended.
Choice D rationale:
Encouraging the client to talk about feelings prior to maladaptive behavior can be beneficial. It can help the client develop healthier coping mechanisms.
Choice E rationale:
Maintaining the same staff members caring for the client can provide consistency and stability, which can be beneficial for individuals with Borderline Personality Disorder.
Choice F rationale:
Initiating suicide precautions is crucial in this situation. The client has a history of suicidal ideation and is exhibiting self-harming behavior.
Choice G rationale:
Offering the client opportunities for physical exercise can be beneficial as it can help manage stress and improve mood.
Choice H rationale:
Exploring feelings of abandonment with the client can be beneficial. It can help the client process these feelings in a healthier way.

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Correct Answer is D

Explanation

Choice A rationale:

Drinking green tea does not directly cause lithium toxicity.

Choice B rationale:

Moderate exercise does not directly cause lithium toxicity.

Choice C rationale:

Increasing sodium intake does not directly cause lithium toxicity. In fact, a sudden decrease in sodium intake can increase the risk of lithium toxicity.

Choice D rationale:

Experiencing diarrhea can lead to dehydration, which increases the risk of lithium toxicity by reducing the excretion of lithium.

A. "You will need to stop this medication if you experience diarrhea.”. B. "You will need to take this medication on an empty stomach.”. C. "You will need to consume a low-salt diet while on this medication.”. D. "You will need your blood levels drawn weekly during the first month.”.

Correct Answer is D

Explanation

Choice A rationale:
Diarrhea is not a specific reason to stop lithium. However, severe diarrhea can affect lithium levels and should be reported to a healthcare provider.
Choice B rationale:
Lithium does not need to be taken on an empty stomach. It can be taken with or without food.
Choice C rationale:
A low-salt diet is not recommended while on lithium. In fact, a consistent, normal sodium intake is important because low sodium levels can cause lithium levels to become too high.
Choice D rationale:
Regular blood tests are necessary when taking lithium to ensure therapeutic levels and prevent toxicity. Weekly blood tests may be required during the first month of treatment.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?

Correct Answer is D

Explanation

A nurse is preparing to teach a client about his prescription of lithium for the treatment of bipolar disorder. Which of the following statements should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is assessing for the presence of extrapyramidal side effects (EPS) in a client who is taking chlorpromazine. Which of the following findings should the nurse recognize as EPS? (Select all that apply.).

A nurse is teaching a client who has bipolar disorder about lithium. Which of the following statements should the nurse include in the teaching?.

A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following responses should the nurse make first?

A nurse is reviewing medication records for several clients who have bipolar disorder. The nurse should recognize that which of the following medications are used to treat clients who have bipolar disorder.(Select all that apply.).

A nurse is reviewing medications for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following client prescriptions should the nurse realize is expected to reduce the client's mania?.

A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client?

A nurse is caring for a client who is experiencing suicidal thoughts. Which of the following actions should the nurse take?.

A nurse is caring for a client who was recently diagnosed with somatic symptom disorder. The client says to the nurse, "I don't understand, they can't find anything medically wrong with me. I guess I will never feel better.”. Which of the following responses is the most therapeutic?