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 C
Explanation
A. Comprehend spoken words: This is part of global aphasia, but it does not fully encompass the deficits associated with this condition. Global aphasia involves more extensive language impairment.
B. Form words that are understandable: This is part of global aphasia, but it alone does not fully capture the severity of the language deficit, as it also includes comprehension issues.
C. Form words that are understandable or comprehend spoken words: Global aphasia is the most severe form of aphasia, characterized by profound impairment in both the ability to produce understandable speech and comprehend spoken language. This choice accurately reflects the full scope of the language deficits in global aphasia.
D. Speak at all: Clients with global aphasia may still attempt to speak, but their speech is typically not understandable and is often meaningless. Therefore, saying they cannot "speak at all" is not entirely accurate.
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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