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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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

Explanation

Choice A reason:

Individuals with Paranoid Personality Disorder often exhibit distrust and suspicion of others. A matter-of-fact approach is beneficial as it avoids emotional engagement that could be perceived as threatening or deceitful. This approach helps in maintaining clear boundaries and reduces the potential for misunderstanding or paranoia.

Choice B reason:

For those with Avoidant Personality Disorder, a matter-of-fact approach might not be as effective because these individuals are often sensitive to negative evaluation and rejection. They may require a more supportive and encouraging approach to help them feel more comfortable in social interactions.

Choice C reason:

People with Schizotypal Personality Disorder display eccentric behaviors and have difficulty forming close relationships. A matter-of-fact approach can provide structure and clarity without overwhelming them with emotional intensity, which they may find difficult to process.

Choice D reason:

Individuals with Narcissistic Personality Disorder may not respond well to a matter-of-fact approach as they often have an inflated sense of self-importance and a need for admiration. They may perceive this approach as dismissive or not adequately acknowledging their perceived self-worth.

Choice E reason:

Those diagnosed with antisocial personality disorder tend to disregard the rights of others and may manipulate or treat others harshly. A matter-of-fact approach is useful as it sets clear expectations and limits, which is necessary to manage potentially manipulative or harmful behaviors.

A. Blunt affect B. Poor judgments C. Delusions D. Anhedonia E. Hallucinations

Correct Answer is ["A","D"]

Explanation

Choice A reason: Blunt affect is a negative symptom of schizophrenia, characterized by a significant reduction in the expression of emotions.

Choice B reason: Poor judgments are not specifically categorized as negative symptoms; they can be a result of cognitive deficits associated with schizophrenia.

Choice C reason: Delusions are considered positive symptoms of schizophrenia, involving false beliefs maintained despite evidence to the contrary.

Choice D reason: Anhedonia, the inability to experience pleasure, is a negative symptom of schizophrenia, reflecting a diminished interest or pleasure in all or almost all activities.

Choice E reason: Hallucinations are considered positive symptoms of schizophrenia, involving perceiving things that are not present.

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 planning the type of approach that will be most effective in developing a therapeutic relationship with the client. With which types of personality disorders should the nurse use a matter-of-fact approach? (Select all that apply)

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

Explanation

A nurse in a mental health clinic is conducting a staff education session on schizophrenia. Which of the following manifestations should the nurse identify as negative symptoms? Select all that apply.

Correct Answer is ["A","D"]

Explanation

The nurse is talking with the spouse of a client admitted for substance use disorder and overdose. Which statement(s) made by the spouse indicates that they are exhibiting enabling behaviors? Select all that apply.

The nurse is performing an assessment for a client brought in by a family member who states they think the client has dementia. When evaluating the assessment data, which finding indicates that the client may likely have delirium and not dementia?

A nurse is providing care to a client with a situational phobia. Which techniques would the nurse most likely include as an intervention in the client's plan of care? (Select all that apply.)

The nurse provides education to a client's family about the client's eating disorder, anorexia nervosa. Which statement would indicate that the education was effective?

A nurse is working with clients diagnosed with personality disorders. Which techniques would be most important for the nurse to use to effectively deal with the frustration in providing care to this group of clients? Select all that apply.

A client and their spouse come to talk with the nurse about their suspicion that the client may have intermittent explosive disorder after researching it on the internet. Which behaviors reported by the spouse indicate that the client may be experiencing this disorder? (Select all that apply.)

The nurse is planning the care of a client with bipolar disorder and addiction to heroin who is in a rehabilitation facility. Which outcomes will the nurse assign in the immediate phase after withdrawal symptoms are over? (Select all that apply.)