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 B
Explanation
A. Assisting the client with meals: Assisting the client with meals is appropriate, as clients with dysphagia may need help to ensure safe swallowing and to avoid choking or aspiration.
B. Placing food on the affected side of the mouth: This is contraindicated because placing food on the affected side could increase the risk of choking or aspiration, as the client may not have adequate control over swallowing on the affected side.
C. Testing the gag reflex before offering food or fluids: Testing the gag reflex is appropriate for ensuring that the client has an intact protective reflex before eating or drinking, reducing the risk of aspiration.
D. Allowing ample time to eat: Allowing the client ample time to eat is important to prevent rushing, which could increase the risk of choking or aspiration. It ensures that the client can safely swallow their food.
Correct Answer is B
Explanation
A. "Do you go by he, she, or they?" This question is direct and acknowledges the importance of pronouns, but it might be better phrased to be more open-ended and respectful.
B. "What pronouns do you go by?" This is the most respectful and open-ended approach, allowing the client to express their preferred pronouns without making assumptions. It demonstrates a clear understanding of the importance of gender identity and respects the client's autonomy.
C. "What led to this hospital admission?" While this question is relevant to the client’s care, it does not address the client's gender identity directly, which is crucial in this context.
D. "What brings you in today?" Similar to option C, this question focuses on the reason for the hospital visit but does not address the client's gender identity, missing an opportunity to show respect for their identity.
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