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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Use the Z-track technique to administer the medication.: The Z-track technique prevents irritation by sealing the medication within the muscle tissue.
B. Administer the medication with a 27-gauge 1/2-inch needle.: IM injections require a longer needle, typically 1–1.5 inches, and a larger gauge, such as 21–25.
C. Inject the medication at least 5 cm (2 in) from the umbilicus.: This is relevant for subcutaneous injections, not IM injections.
D. Give the medication without aspirating prior to injection.: Aspiration is not always required for IM injections but is often practiced for safety when administering certain medications.
Correct Answer is D
Explanation
A. "I understand that the medication can slow my heart rate.": Nitroglycerin works by dilating blood vessels, which can reduce blood pressure but does not significantly slow the heart rate.
B. "I am going to take the medication with food.": Nitroglycerin should be taken sublingually without food, as food can interfere with its absorption.
C. "I will take the medication every 10 minutes until the pain goes away.": The typical recommendation is to take 1 tablet every 5 minutes for up to 3 doses; if pain persists, seek medical attention.
D. "I should feel the effects of the medication within 5 minutes.": Sublingual nitroglycerin typically works within 1-3 minutes to relieve chest pain.
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