A nurse is providing discharge teaching to a client diagnosed with bipolar disorder who will be discharged with a prescription for lithium. The nurse should teach the client that which of the following is a risk factor for lithium toxicity?

The client eats foods high in tyramine.

The client runs 4 miles outdoors every afternoon.

The client drinks 2 liters of liquids daily.

The client eats 2 to 3 grams of sodium-containing foods daily.

Answer and Explanation

The Correct Answer is B

Choice A reason:
Eating foods high in tyramine is not a risk factor for lithium toxicity. Tyramine is associated with dietary restrictions in patients taking monoamine oxidase inhibitors, not lithium.

Choice B reason:
Engaging in activities that cause excessive sweating, such as running 4 miles outdoors every afternoon, can lead to dehydration. Dehydration is a significant risk factor for lithium toxicity because it can increase lithium levels in the blood, potentially leading to toxicity.

Choice C reason:
Drinking 2 liters of liquids daily is generally recommended for hydration and is not a risk factor for lithium toxicity. Adequate hydration can help prevent lithium toxicity by ensuring that lithium is properly excreted through the kidneys.

Choice D reason:
Eating 2 to 3 grams of sodium-containing foods daily is within normal dietary intake ranges and is not a risk factor for lithium toxicity. Maintaining a consistent sodium intake is important when taking lithium, as low sodium levels can lead to increased lithium retention and potential toxicity.

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Correct Answer is B

Explanation

Choice A reason:
Locking the doors and securing windows may prevent an escape attempt, but it does not address immediate risks within the client's environment. It can also make the client feel trapped or punished, which could exacerbate their distress.

Choice B reason:
Removing any objects that could be used for self-harm is a direct intervention that reduces immediate risk. It is a standard safety precaution in managing suicidal clients and helps create a safer environment while further assessments and interventions are planned.

Choice C reason:
Providing plastic eating utensils is a safety measure, but it is not as comprehensive as removing all objects that could be used for self-harm. This action should be part of a broader strategy to ensure safety.

Choice D reason:
Assigning a staff member to stay with the client can provide supervision and prevent an attempt at self-harm. However, it may not be feasible as a long-term solution and does not remove the means for self-harm.

A. Risk for aspiration related to impaired gag reflex. B. Risk for injury related to impaired coordination and judgment. C. Impaired liver function related to alcohol toxicity. D. Risk for falls related to dizziness and unsteady gait. E. Risk for infection related to impaired immune function.

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

Explanation

Choice A Reason:
Aspiration is a significant risk for clients with acute alcohol intoxication due to an impaired gag reflex. Alcohol can depress the central nervous system, leading to a decreased level of consciousness and a diminished gag reflex, which increases the risk of aspiration of gastric contents into the lungs.

Choice B Reason:
Impaired coordination and judgment are common in acute alcohol intoxication, increasing the risk of injury. Alcohol affects the cerebellum, the part of the brain that regulates coordination and balance, as well as the frontal lobes, which are responsible for judgment and decision-making.

Choice C Reason:
Alcohol is metabolized by the liver, and excessive alcohol intake can lead to alcohol toxicity and liver impairment. Acute alcohol intoxication can cause hepatic steatosis, alcoholic hepatitis, and even acute liver failure in severe cases.

Choice D Reason:
Dizziness and an unsteady gait are direct effects of alcohol's impact on the vestibular system and the brain's ability to process spatial information, leading to an increased risk of falls.

Choice E Reason:
Alcohol intoxication can impair immune function, making the client more susceptible to infections. Alcohol disrupts immune pathways in complex ways, which can impair the body's ability to defend against infections

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A nurse is providing discharge teaching to a client diagnosed with bipolar disorder who will be discharged with a prescription for lithium. The nurse should teach the client that which of the following is a risk factor for lithium toxicity?

Nursing Test Bank

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Explanation

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