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","C","D"]
Explanation
A. Vital signs. The client has a significantly elevated heart rate (110/min) and elevated blood pressure (178/82 mm Hg), both of which can be associated with autonomic responses in dumping syndrome. The dizziness and desire to lie down after eating are also classic symptoms. These signs reflect the body’s reaction to rapid gastric emptying and fluid shifts.
B. Prescribed diet. While a bland, soft diet is generally safe post-gastrectomy, it may not prevent dumping syndrome unless it includes specific modifications like low carbohydrate intake and small, frequent meals. However, this option alone does not directly indicate dumping syndrome.
C. Skin appearance. The client is noted to be diaphoretic and pale, which are common symptoms of dumping syndrome due to the vasomotor response and hypoglycemia that can follow rapid gastric emptying.
D. Blood glucose level. The client's fasting blood glucose dropped to 65 mg/dL, which is below the normal range. Hypoglycemia is a hallmark of late dumping syndrome, resulting from excessive insulin release after rapid carbohydrate absorption in the small intestine.
E. WBC count. The WBC count is within normal range (9,000/mm³) and does not indicate dumping syndrome or an infectious process. It is not relevant in this context.
Correct Answer is C
Explanation
A. Remove the safety inspection sticker before plugging in the IV pump. The safety inspection sticker is proof that the equipment has passed a required check. It should not be removed, as doing so may violate facility policies and regulatory standards.
B. Grasp the IV pump cord when unplugging it from the electrical outlet. Pulling on the cord rather than the plug itself can damage the cord or outlet and pose an electrical hazard. Always unplug by gripping the plug directly.
C. Check the cords of the IV pump for fraying. Inspecting cords for fraying or damage is essential before using any electrical equipment. Damaged cords can lead to electric shock, equipment failure, or fire, and must be reported and replaced.
D. Ensure that the electric outlet has two prongs for the IV pump. Medical equipment should be plugged into a three-pronged (grounded) outlet to prevent electrical shock. Two-prong outlets are not grounded and are inappropriate for hospital-grade devices.
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