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.
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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Related Questions
Correct Answer is ["A","B"]
Explanation
A. blurred vision: Blurred vision is a common side effect of tricyclic antidepressants due to their anticholinergic effects, and it can be a sign of overdose.
B. urinary retention: Urinary retention is another anticholinergic side effect of tricyclic antidepressants and can indicate an overdose.
C. diarrhea: Diarrhea is not typically associated with tricyclic antidepressant overdose. Anticholinergic effects generally lead to constipation, not diarrhea.
D. headache: While a headache can occur in many situations, it is not a specific indicator of tricyclic antidepressant overdose.
E. pale, moist skin: Pale, moist skin is not a typical symptom of tricyclic antidepressant overdose. Overdose symptoms more commonly include dry skin due to anticholinergic effects.
Correct Answer is D
Explanation
A. "Are you frightened?" This response is empathetic but may inadvertently reinforce the client's delusional thinking by focusing on the fear rather than addressing the delusion.
B. "You know I'm not following you." This response directly challenges the client's delusion, which could provoke defensiveness and escalate the situation.
C. "You'll have to go into seclusion if you continue to threaten me." This response is confrontational and may escalate the situation further by implying a threat, which could increase the client's fear and anger.
D. "I'm sorry if I frightened you. I was returning to the nurses' station after going out for lunch." This response acknowledges the client's feelings without reinforcing the delusion and provides a simple, non-threatening explanation for the nurse's actions. It helps de-escalate the situation by maintaining a calm, non-confrontational tone.
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