Which of the following nursing interventions should a nurse perform when caring for a female client with mood disorder who is prescribed lithium?

Instruct to resume regular activities such as driving.

Administer lithium before meals.

Withhold if serum level is less than 1.5 mEq.

Instruct to avoid breastfeeding.

Answer and Explanation

The Correct Answer is D

A. Instruct to resume regular activities such as driving. It is not safe to instruct the client to resume activities like driving immediately, especially at the beginning of lithium therapy, as lithium can cause side effects that may impair the client's ability to safely perform tasks such as driving.

B. Administer lithium before meals. Lithium is typically taken with food to minimize gastrointestinal upset. Administering it before meals may increase the risk of side effects like nausea.

C. Withhold if serum level is less than 1.5 mEq. Lithium should be withheld if the serum level is above the therapeutic range (typically 0.6–1.2 mEq/L), as higher levels can lead to toxicity. Withholding lithium if the level is less than 1.5 mEq/L is incorrect and could lead to inadequate treatment.

D. Instruct to avoid breastfeeding. Lithium is excreted in breast milk and can pose a risk to the infant, so the client should be advised against breastfeeding while on lithium therapy.

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Correct Answer is A

Explanation

A. "My condition is a degenerative brain disorder caused by nutrient deficiency." Wernicke encephalopathy is caused by thiamine (vitamin B1) deficiency, which is often due to chronic alcoholism. The condition is associated with neurological damage from this nutrient deficiency, making this statement accurate.

B. "There is swelling of my brain that is caused by alcohol consumption." Wernicke encephalopathy is not characterized by brain swelling but by neurological damage due to thiamine deficiency.

C. "The inability of my liver to metabolize the alcohol caused this condition." While liver dysfunction can be associated with alcohol use, Wernicke encephalopathy is specifically due to thiamine deficiency, not liver metabolism issues.

D. "Toxins from the alcohol I drank have caused my brain to swell." This statement is incorrect as Wernicke encephalopathy is related to thiamine deficiency rather than brain swelling from alcohol toxins.

A. Maintaining accurate records of intake and output B. Maintaining a patent airway C. Inserting a nasogastric (NG) tube as prescribed D. Providing appropriate pain control

Correct Answer is B

Explanation

A. Maintaining accurate records of intake and output: While monitoring intake and output is important for assessing fluid balance and kidney function, it is not as immediate a concern as maintaining an airway in an unconscious client.

B. Maintaining a patent airway: This is the highest priority because an unconscious client is at high risk of airway obstruction due to the loss of protective reflexes. Ensuring that the airway remains open is critical to prevent respiratory distress or arrest.

C. Inserting a nasogastric (NG) tube as prescribed: Inserting an NG tube might be necessary for feeding or draining gastric contents, but it is secondary to the more urgent need of ensuring a clear airway.

D. Providing appropriate pain control: Pain control is important but should be considered after addressing more immediate threats to the client's safety, such as maintaining a patent airway.

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Which of the following nursing interventions should a nurse perform when caring for a female client with mood disorder who is prescribed lithium?

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