A nurse in a mental health facility is collecting data from a client taking lithium. Which of the following information should the nurse report to the provider as an indication of lithium toxicity?
Dry cough
Elevated blood pressure
Stooped posture
Slurred speech
The Correct Answer is D
A. Dry cough: This is not typically associated with lithium toxicity and may indicate another issue, such as a respiratory infection.
B. Elevated blood pressure: Lithium toxicity usually results in hypotension, not elevated blood pressure.
C. Stooped posture: This is not a typical sign of lithium toxicity.
D. Slurred speech: Slurred speech can be an early sign of lithium toxicity, indicating that the medication level is too high.
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Correct Answer is D
Explanation
A. Calculate the correct amount of the medication: This is an important step but should be done after confirming the client's identity to ensure medication safety.
B. Validate the prescription with the available medication: Validating the prescription is essential, but client identification should be the priority before administering the medication.
C. Document the time of the medication administration: Documentation is done after the medication is administered, and client identification must come first.
D. Identify the client using two means of identification: This is the most critical first step to ensure the correct patient is receiving the correct medication.
Correct Answer is C
Explanation
A. Increasing the dose too soon is inappropriate; therapeutic effects take time to manifest.
B. Amitriptyline can be taken with or without food; stomach contents do not affect its efficacy.
C. Most antidepressants, including amitriptyline, require 2-4 weeks for therapeutic effects. The client needs reassurance and education.
D. Switching medications prematurely is unnecessary unless severe side effects occur.
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