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.

"This medication can cause nausea and drowsiness."

"You will be placed on a low-sodium diet while taking this medication."

"Blurred vision is an expected adverse effect of this medication."

"This medication can cause weight gain."

"It will take at least a week before this medication reachesa therapeutic level."

Answer and Explanation

Correct Answer : A,D,E

A. "This medication can cause nausea and drowsiness.": Gastrointestinal upset and central nervous system effects such as drowsiness are common early adverse effects of lithium therapy. Clients should be informed so they can recognize mild side effects versus signs of toxicity.

B. "You will be placed on a low-sodium diet while taking this medication.": Lithium requires a consistent, not low, sodium intake. Low sodium can increase lithium reabsorption in the kidneys, raising the risk of toxicity. Emphasizing a consistent dietary sodium intake is important rather than restricting sodium.

C. "Blurred vision is an expected adverse effect of this medication.": Blurred vision is not an expected side effect of lithium and may indicate toxicity or another ocular issue. Clients should report changes in vision promptly rather than consider them routine.

D. "This medication can cause weight gain.": Weight gain is a known side effect of lithium therapy due to fluid retention and metabolic changes. Clients and caregivers should be aware to monitor weight and maintain healthy lifestyle practices.

E. "It will take at least a week before this medication reaches a therapeutic level.": Lithium requires several days to reach a therapeutic blood level, and effects on mood stabilization are gradual. Educating the client about delayed onset helps set realistic expectations and encourages adherence.

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Correct Answer is A

Explanation

A. Ask the client to rate their pain on a scale of 0 to 10: Pain assessment is the first step in managing pain effectively. Using a standardized pain scale helps determine the severity, effectiveness of the previous dose, and guides subsequent interventions or medication adjustments.

B. Request a prescription for an opioid pain medication for the client: While opioids may be appropriate for breakthrough pain, the nurse must first assess the current pain level and response to prior medication before requesting additional prescriptions. Immediate escalation is premature without assessment.

C. Report this client finding to the provider: Reporting is important if pain persists despite interventions, but initial assessment and documentation of pain severity should precede notifying the provider to provide accurate information.

D. Administer an additional dose of ibuprofen to the client: Administering another dose without verifying timing, maximum daily dosage, or assessing pain response could risk overdose or toxicity. Pain assessment must guide safe medication administration.

A. Encourage exercise 1 hr prior to sleep. B. Provide a warm cup of coffee 30 min before bedtime. C. Turn on the client's television at bedtime. D. Encourage the client to take a warm bath before bedtime.

Correct Answer is D

Explanation

A. Encourage exercise 1 hr prior to sleep: Vigorous exercise immediately before bedtime can increase alertness and delay sleep onset. Exercise is best scheduled earlier in the day to promote better sleep quality.

B. Provide a warm cup of coffee 30 min before bedtime: Caffeine is a stimulant that can interfere with the ability to fall and stay asleep. Offering coffee close to bedtime is counterproductive to promoting sleep.

C. Turn on the client's television at bedtime: Television and other electronic devices emit light and provide stimulation that can disrupt circadian rhythms and inhibit melatonin release, making it harder to fall asleep.

D. Encourage the client to take a warm bath before bedtime: A warm bath helps relax muscles and promotes a decrease in core body temperature afterward, which can facilitate sleep onset. This is an effective, nonpharmacologic intervention to improve sleep quality.

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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.

Nursing Test Bank

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Explanation

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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.