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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason: Demonstrating alternative ways to deal with stress and anxiety is a measurable outcome, as the client can be observed utilizing different coping strategies in response to stressors.

Choice B reason: The ability to verbally express emotional feelings is an important therapeutic goal for clients with somatic symptom disorder, as it can help them articulate emotions rather than expressing them through physical symptoms.

Choice C reason: Identifying the relationship between stress and physical symptoms is a key component of managing somatic symptom disorder, as it helps the client understand how psychological factors can manifest physically.

Choice D reason: Learning to vary their schedule can help the client avoid routines that may contribute to stress, providing a sense of control and flexibility.

Choice E reason: Assuming responsibility for self-care activities is a significant step towards empowerment and self-management, which is essential for long-term treatment success.

A. Exploring B. Silence C. Voicing doubt D. Challenging E. Disapproving F. Agreeing

Correct Answer is ["D","E","F"]

Explanation

Choice A reason: Exploring is a therapeutic technique that involves delving into a client's experiences and feelings, which can be beneficial in understanding their perspective.

Choice B reason: Silence can be a therapeutic technique that gives clients space to think and express themselves.

Choice C reason: Voicing doubt can undermine the client's confidence and is not considered a therapeutic response.

Choice D reason: Challenging may confront the client in a non-therapeutic way, potentially leading to defensiveness.

Choice E reason: Disapproving can make clients feel judged and is not conducive to a therapeutic relationship.

Choice F reason: Agreeing may not always be therapeutic as it can prevent clients from exploring all aspects of their issues.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is creating a plan of care for a client with somatic symptom disorder. Which long-term treatment outcomes for this client will be most achievable and measurable? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

The nurse is performing a history and physical assessment for a client in the clinic with moderate dementia. The client asks the nurse why all of these questions are being asked. Which techniques will the nurse most likely avoid using to foster more therapeutic responses? Select all that apply.

Correct Answer is ["D","E","F"]

Explanation

A client diagnosed with Schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should the nurse expect a physician to order to address this type of symptom?

A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? Select all that apply.

The nurse is talking with a client diagnosed with histrionic personality disorder. Which statement made by the client does the nurse identify as correlating with this diagnosis?

A nurse in an acute care mental health facility is preparing to administer morning medication to a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?

The nurse is working with clients with personality disorders that are having problems with relationships and other parts of their life. Which barrier(s) is the nurse experiencing when working with this group of clients? Select all that apply.

A nurse on an inpatient eating disorders unit is caring for a client who has anorexia nervosa with a body mass index (BMI) of 17.2. Which of the following actions should the nurse take? Select all that apply.

A male nurse is assigned to care for a female client who was admitted to the hospital for treatment of injuries following a domestic abuse incident. The client expresses discomfort with a male nurse as her caregiver. Which response should the nurse manager provide?

A nurse is assessing risk factors for suicide. Which of the following should the nurse consider? Select all that apply.