The nurse is continuing to care for the client.
The nurse is providing teaching about lithium to the client and the client's adult child.
Select the 3 statements the nurse should include.
"Blurred vision is an expected adverse effect of this medication,"
"This medication can cause weight gain."
"This medication can cause nausea and drowsiness."
"It will take at least a week before this medication reaches a therapeutic level."
"You will be placed on a low-sodium diet while taking this medication."
Correct Answer : B,C,D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Flush the tubing with 30 mL of water every 4 hr. Flushing the tube regularly helps maintain patency, prevent clogging, and ensure that the feeding is delivered effectively. This is a standard practice in managing enteral feeding systems.
B. Check for gastric residual every 12 hr. Gastric residuals should typically be checked every 4 to 6 hours, or per facility protocol, especially in clients at risk for aspiration. Waiting 12 hours is too long and may delay identifying feeding intolerance.
C. Place enough formula in the container to last 18 hr. Open systems should have fresh formula added every 4 hours to reduce the risk of bacterial contamination. Leaving formula in the feeding bag for 18 hours exceeds safety guidelines and increases infection risk.
D. Maintain bed elevation at 20°. The head of the bed should be elevated to at least 30 to 45 degrees to reduce the risk of aspiration. A 20° elevation is insufficient and does not provide adequate protection during feeding.
Correct Answer is B
Explanation
A. Trim the fat from red meat prior to cooking. Children with cystic fibrosis often have difficulty absorbing fats due to pancreatic insufficiency, but they actually need higher fat intake to meet their increased energy demands. Trimming fat is not necessary or recommended.
B. Provide a diet high in protein and calories. Children with cystic fibrosis require a high-calorie, high-protein diet to support growth, maintain weight, and compensate for the energy lost due to chronic lung infections and malabsorption.
C. Administer pancreatic enzymes 30 min after meals. Pancreatic enzymes should be given before or with meals and snacks to aid digestion. Giving them 30 minutes after a meal reduces their effectiveness.
D. Give the child hot foods to reduce the sense of fullness. There is no evidence to support using hot foods to manage fullness in cystic fibrosis. Instead, meals should be nutrient-dense and timed to optimize digestion and absorption.
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