A client with bipolar disorder has been taking lithium, and today his serum blood level is 2.0 mEq/L. What effects would the nurse expect to see?
None; the serum level is in therapeutic range.
Fever, muscle rigidity, and disorientation.
Nausea, diarrhea, and confusion.
Constipation and postural hypotension.
The Correct Answer is C
Choice A reason: The therapeutic range for lithium is 0.6–1.2 mEq/L. A level of 2.0 mEq/L indicates toxicity, not therapeutic safety.
Choice B reason: Fever, muscle rigidity, and disorientation are more consistent with neuroleptic malignant syndrome, not lithium toxicity.
Choice C reason: Lithium toxicity commonly presents with gastrointestinal symptoms (nausea, diarrhea) and neurological changes (confusion, tremors). At 2.0 mEq/L, these are expected findings.
Choice D reason: Constipation and postural hypotension are not typical signs of lithium toxicity. They may occur with other medications but are not the primary effects of elevated lithium levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Hot flashes can disrupt sleep, especially in menopausal women, but they are not the defining feature of psychophysiological insomnia.
Choice B reason: Stress and anxiety are the primary causes of psychophysiological insomnia. This type of insomnia develops when worry and tension interfere with the ability to relax and initiate sleep. Clients often become preoccupied with their inability to sleep, which perpetuates the cycle.
Choice C reason: Pain can cause secondary insomnia, but it is classified as insomnia due to a medical condition rather than psychophysiological insomnia.
Choice D reason: Headaches may disturb sleep but are not the central mechanism of psychophysiological insomnia. The disorder is more directly linked to stress and anxiety.
Correct Answer is ["C","D","E","F"]
Explanation
Choice A reason: Lethargy is not a typical sign of alcohol withdrawal. Instead, withdrawal is characterized by hyperactivity of the autonomic nervous system, not sedation or fatigue. Lethargy is more often seen with intoxication rather than withdrawal.
Choice B reason: Blackouts occur during episodes of heavy drinking due to acute intoxication and memory impairment, not during withdrawal. Withdrawal symptoms are related to the absence of alcohol and the rebound hyperexcitability of the nervous system.
Choice C reason: Nausea is a common symptom of alcohol withdrawal. The gastrointestinal system becomes irritated, and autonomic hyperactivity contributes to nausea and vomiting. This is a well-recognized clinical feature.
Choice D reason: Tremulousness, or hand tremors, is one of the hallmark signs of alcohol withdrawal. It results from central nervous system hyperexcitability when alcohol is abruptly discontinued. Tremors are often the first noticeable symptom.
Choice E reason: Diaphoresis, or excessive sweating, is a classic autonomic symptom of alcohol withdrawal. It reflects increased sympathetic nervous system activity, which is a direct consequence of withdrawal.
Choice F reason: Elevated blood pressure is another autonomic sign of alcohol withdrawal. The absence of alcohol leads to increased sympathetic tone, causing hypertension and tachycardia. This is a critical sign to monitor because it can progress to more severe complications such as seizures or delirium tremens.
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