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 ["A","C","E"]

Explanation

Choice A reason: Ongoing communication with team members is essential in managing care for clients with personality disorders, as it ensures consistency and support among caregivers.

Choice B reason: Solving clients' problems is a goal, but it is not a technique to manage the nurse's frustration.

Choice C reason: Recognizing that behavior changes can occur quickly allows the nurse to adjust care plans promptly and may reduce frustration.

Choice D reason: It is not advisable to consider clients as personal friends, as this can blur professional boundaries and potentially lead to frustration.

Choice E reason: Discussing feelings of anger or frustration with colleagues can provide a support system for the nurse, helping to manage stress and prevent burnout.

A. "Did your husband say something to upset you?" B. "Tell me what is concerning you." C. "Your husband is making really good progress!" D. "Did something bad happen to your husband?"

Correct Answer is B

Explanation

The correct answer is: "Tell me what is concerning you."

Choice A reason:

Asking "Did your husband say something to upset you?" may seem accusatory and could lead the spouse to feel defensive. It does not open a dialogue for the spouse to express their concerns freely and can be perceived as leading the conversation in a negative direction.

Choice B reason:

"Tell me what is concerning you." is an open-ended statement that invites the spouse to share their feelings and concerns. It demonstrates empathy and active listening, which are key components of therapeutic communication. This response encourages the spouse to elaborate on their feelings and fosters a supportive environment.

Choice C reason:

Saying "Your husband is making really good progress!" is reassuring, but it does not address the spouse's current emotional state or concerns. It may come across as dismissive of the spouse's feelings and does not encourage further discussion about their worries.

Choice D reason:

Asking "Did something bad happen to your husband?" can increase anxiety and assumes a negative event has occurred. It is not a therapeutic response because it does not provide comfort or support to the spouse in a stressful situation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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.

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

Explanation

A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is a therapeutic nursing response?

Correct Answer is B

Explanation

A community health nurse is providing teaching to the family of a client who has primary dementia. Which of the following manifestations should the nurse tell the family to expect?

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Which statement(s) made by the spouse indicates that they are exhibiting enabling behaviors? Select all that apply.

The nurse is educating a client about their diagnosis of somatization disorder prior to the termination phase of the nurse-client relationship. Which statement by the client indicates a need for additional teaching?

A client has a history of excessive fear of water. Which term should the nurse use to describe this specific phobia, and under what subtype is this phobia identified?