A nurse is planning to teach a client who is taking lithium. Which of the following should the nurse include in the teaching as adverse effects of therapeutic lithium level?

Weight gain and dry mouth

Oliguria and muscle weakness

Hallucinations and blurred vision

Coarse hand tremors and confusion

Answer and Explanation

The Correct Answer is A

A. Weight gain and dry mouth: Weight gain and dry mouth are common adverse effects of lithium at therapeutic levels. They are not immediately dangerous but can affect compliance with the medication regimen.

B. Oliguria (reduced urine output) and muscle weakness are more concerning symptoms. They can indicate potential toxicity, especially oliguria, which suggests possible renal impairment, a serious concern with lithium therapy.

C. Hallucinations and blurred vision are more severe and typically associated with lithium toxicity rather than therapeutic levels. They indicate a need for immediate medical attention.

D. Coarse hand tremors and confusion: Coarse hand tremors and confusion are signs of lithium toxicity. At therapeutic levels, fine hand tremors can occur, but coarse tremors and confusion suggest higher serum levels.These symptoms are associated with toxicity and require urgent medical evaluation.

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Correct Answer is B

Explanation

A. Give the client a cup of hot black tea before bed: Consuming caffeinated beverages such as black tea before bed can interfere with sleep and exacerbate sleep disturbances. This instruction is not appropriate for addressing sleep issues in Alzheimer's disease.

B. Wake the client at the same time each morning: Maintaining a consistent wake-up time can help regulate the client's sleep-wake cycle and promote better sleep hygiene. Consistency in waking time is an important aspect of managing sleep disturbances in Alzheimer's disease.

C. Take the client for a walk 2 hours before bedtime each night: Engaging in physical activity during the day, including taking a walk, can promote better sleep patterns. However, engaging in vigorous physical activity close to bedtime may have the opposite effect and disrupt sleep.

D. Allow the client to take a 90-min nap immediately after lunch: While brief daytime naps may be beneficial for some individuals with Alzheimer's disease, allowing a 90-minute nap immediately after lunch may interfere with the client's ability to consolidate nighttime sleep and worsen sleep disturbances.

A. Document the client's behavior once every hour. B. Keep the client in restraints until the prescription expires. C. Conduct a debriefing regarding the client with the unit staff D. Request an evaluation of the client within 12 hr of application of restraints

Correct Answer is C

Explanation

A. Documentation should occur every 15-30 minutes to ensure the client's safety and to assess the need for continuing or removing the restraints.

B. Keep the client in restraints until the prescription expires: Restraints should be used for the shortest duration necessary to ensure the safety of the client and others. Keeping the client restrained until the prescription expires without reevaluation may not align with best practices for restraint use.

C. Conducting a debriefing with the unit staff is crucial to evaluate the situation, discuss the events leading up to the use of restraints, and develop strategies to prevent the need for future restraint use. This helps ensure the safety and well-being of the client and others, as well as improve care practices.

D.Typically, the evaluation should occur within 1-4 hours depending on the facility's policy and the urgency of the situation.

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A nurse is planning to teach a client who is taking lithium. Which of the following should the nurse include in the teaching as adverse effects of therapeutic lithium level?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to the caretakers of a client who has Alzheimer's disease with mild cognitive decline. The client is beginning to experience sleep disturbances. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse is caring for a client who is aggressive toward other clients and has been placed in wrist restraints. After obtaining a prescription for restraints from the provider, which of the following actions should the nurse take?

Correct Answer is C

Explanation

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