A nurse is caring for a client who has an extremely elevated lithium level. Which of the following actions should the nurse take?

Prepare for gastric lavage.

Hold the medication and assess for early manifestations of toxicity.

Check the client's medication record to assess whether the client has been refusing her lithium.

Administer the morning dose of lithium.

Answer and Explanation

The Correct Answer is B

Choice A reason: Gastric lavage is typically not the first-line treatment for lithium toxicity due to the risk of aspiration and potential complications. It is usually reserved for cases where the ingestion was recent and massive.

Choice B reason: When a client presents with an extremely elevated lithium level, it is crucial to hold further doses to prevent exacerbation of toxicity. The nurse should monitor for early signs of toxicity, which include gastrointestinal symptoms like nausea, vomiting, diarrhea, and neurological symptoms such as tremors, confusion, and ataxia. The normal therapeutic range for lithium is 0.6 to 1.2 mmol/L, and levels above 1.5 mmol/L are considered toxic.

Choice C reason: While it is important to review the medication record, the immediate concern with an extremely elevated lithium level is addressing the toxicity. Checking the medication record can be part of the assessment process but is not the priority action.

Choice D reason: Administering the morning dose of lithium could worsen the client's condition by increasing the lithium level further, which is already extremely elevated. This could lead to severe toxicity or even fatal consequences.

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Correct Answer is D

Explanation

Choice A reason: Sleeping 12 hours or more each day can be a response to various stressors, but it is not a specific or expected finding in PTSD.

Choice B reason: A constant need to talk about the event may be part of the processing of trauma, but it is not an expected finding as many individuals with PTSD may avoid discussing the traumatic event.

Choice C reason: An increasing sense of attachment to others is not typically associated with PTSD, as individuals may instead experience detachment or estrangement from others.

Choice D reason: Increasing feelings of anger are common in individuals with PTSD as they may have difficulty controlling anger and may be easily irritated.

A. "It's common for clients who have postpartum depression to exhibit psychotic behavior." B. "The most common manifestation of postpartum depression is harming the infant." C. "Postpartum depression usually begins 48 hours after childbirth." D. "Postpartum depression is more likely to occur in women who have a history of depression."

Correct Answer is D

Explanation

Choice A reason: Psychotic behavior is not common in postpartum depression; it is more associated with postpartum psychosis, a rare and severe form of the condition.

Choice B reason: Harming the infant is not a common manifestation of postpartum depression and is a misconception.

Choice C reason: Postpartum depression does not typically begin 48 hours after childbirth; this is more indicative of the "baby blues," which are less severe and more transient.

Choice D reason: Women with a history of depression are at a higher risk for postpartum depression, making this statement accurate.

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A nurse is caring for a client who has an extremely elevated lithium level. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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