A nurse is collecting data from a client who is taking lithium. Which of the following findings should the nurse identify as early manifestations of lithium toxicity? (Select all that apply.)

Incoordination

Polyuria

Nausea

Convulsions

Confusion

Answer and Explanation

Correct Answer : A,C,E

A.   Incoordination, such as clumsiness or difficulty walking, can be an early sign of lithium toxicity. It reflects the neurological effects of elevated lithium levels on motor coordination.
B.   Polyuria (excessive urination) is a common late symptom of lithium toxicity. Lithium interferes with the kidney's ability to concentrate urine, leading to increased urine output.
C.   Nausea is a gastrointestinal symptom that can occur in the early stages of lithium toxicity. It is often accompanied by other gastrointestinal disturbances such as vomiting and diarrhea.
D.   Convulsions (seizures) are not typically considered early manifestations of lithium toxicity but rather indicate severe toxicity. Seizures can occur at higher levels of lithium toxicity and require immediate medical intervention.
E.   Confusion is another early sign of lithium toxicity. It reflects the impact of elevated lithium levels on the central nervous system, leading to cognitive impairment and altered mental status.

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Correct Answer is C

Explanation

A. Fluoxetine is not indicated for the treatment of seizures. Its primary therapeutic effect is related to mood stabilization through serotonin reuptake inhibition in the brain. Therefore, absence of seizures would not be an expected outcome of fluoxetine therapy.
B. Hand tremors are not typically a direct symptom of depression or anxiety but can occur as a side effect of certain medications or due to anxiety-related physiological responses. Fluoxetine itself does not typically cause or treat hand tremors directly. Therefore, while tremor reduction might occur as a result of improved mood and reduced anxiety, it is not a direct therapeutic outcome of fluoxetine.
C. Improved mood is one of the primary expected outcomes of fluoxetine therapy. SSRIs like fluoxetine work by increasing serotonin levels in the brain, which helps regulate mood and alleviate symptoms of depression and anxiety. Clients typically experience a reduction in feelings of sadness, hopelessness, and anxiety, leading to an overall improvement in mood.
D. Hallucinations are not a typical symptom of depression or anxiety disorders but can occur in conditions such as schizophrenia or psychotic depression. Fluoxetine is not primarily indicated for treating hallucinations.

A. Keep staff interactions with the client to a minimum. B. Provide range-of-motion exercises to all extremities every 2 hr. C. Request the provider renew the prescription in 24 hr. D. Document the client's behavior in the medical record every 1 hr.

Correct Answer is B

Explanation

A. Keeping staff interactions to a minimum may not be beneficial as the client might require regular monitoring and interaction to assess their condition and needs.
B. When a client is restrained, it's crucial to prevent complications such as muscle stiffness and joint contractures. Range-of-motion exercises help maintain circulation, prevent discomfort, and preserve joint mobility. However, this is not the most important action.
C. Restraints should only be used when absolutely necessary and prescribed by a provider. In many jurisdictions and healthcare facilities, the use of restraints requires a specific order that must be renewed periodically (often every 24 hours). This practice ensures that the need for restraints is continually reassessed and that they are not used longer than necessary.
D. Accurate and frequent documentation is essential when a client is restrained. Documentation should include the client's behavior, physical assessments, interventions provided (such as medication administration or hygiene care), and responses to interventions. However, this is not the most important action.

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A nurse is collecting data from a client who is taking lithium. Which of the following findings should the nurse identify as early manifestations of lithium toxicity? (Select all that apply.)

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