A nurse is reinforcing teaching with a client about a new prescription for lithium.
Which of the following statements should the nurse include in the teaching?
Your provider will prescribe a diuretic while you are taking lithium.
Weight gain is a manifestation of lithium toxicity.
We will need to check your lithium levels in the next 3 to 5 days.
Your lithium will be discontinued in 6 months to prevent addiction.
The Correct Answer is C
Rationale for Choice A:
Diuretics are not routinely prescribed with lithium. While diuretics can increase the excretion of lithium, this can also lead to decreased lithium levels and potentially reduced effectiveness. Therefore, diuretics are generally only used in specific situations, such as when a client has lithium-induced edema or congestive heart failure. In such cases, the client's lithium levels would be closely monitored to ensure they remain within the therapeutic range.
Rationale for Choice B:
Weight gain is not a common manifestation of lithium toxicity. In fact, weight gain is a potential side effect of lithium therapy, but it is not typically associated with lithium levels reaching a toxic range. Other signs and symptoms of lithium toxicity include:
Tremor
Nausea and vomiting
Diarrhea
Confusion
Slurred speech
Ataxia
Seizures
Coma
Rationale for Choice C:
Monitoring lithium levels is essential to ensure that the client is receiving a therapeutic dose and to avoid toxicity. Lithium has a narrow therapeutic index, meaning that there is a small difference between the dose that is effective and the dose that is toxic. Regularly checking lithium levels allows the healthcare provider to adjust the dose as needed to maintain a safe and effective level.
The initial lithium level is typically checked within 3 to 5 days of starting the medication, and then periodically thereafter.
The frequency of monitoring may vary depending on the client's individual factors, such as age, kidney function, and other medications they are taking.
Rationale for Choice D:
Lithium is not typically discontinued after a specific period of time. It is often used as a long-term treatment for bipolar disorder to prevent the recurrence of manic and depressive episodes. The decision to discontinue lithium is made on a caseby-case basis, in consultation with the client and their healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Placing a client in restraints should be a last resort, as it can be traumatizing and can escalate agitation.
Restraints can also cause physical injury and psychological distress.
They should only be used when there is an immediate risk of harm to the client or others.
Choice B rationale:
Haloperidol is an antipsychotic medication that can be used to calm agitated clients.
However, it should not be the first-line intervention, as it can have significant side effects, including drowsiness, dizziness, and muscle stiffness.
It is important to assess the client's individual needs and risks before administering haloperidol.
Choice C rationale:
Asking a client to talk about their feelings can be helpful in some situations, but it is not appropriate when a client is agitated and yelling.
The client is likely to be too overwhelmed to engage in meaningful conversation.
It is important to first de-escalate the situation and ensure the safety of everyone involved.
Choice D rationale:
Moving the client to a seclusion room with continuous observation is the most appropriate intervention in this situation.
This will provide the client with a safe and quiet space to calm down.
It will also allow staff to monitor the client closely and intervene if necessary.
Continuous observation is essential to ensure the client's safety and to prevent self-harm.
Correct Answer is A
Explanation
Choice A rationale:
Ideas of reference are a type of delusion in which a person believes that unrelated events, objects, or actions in the environment have personal significance or meaning specifically directed towards them. In this case, the client with schizophrenia misinterpreted the group's laughter as mockery directed specifically at them, even though the story was unrelated to them.
Here's a detailed explanation of why the other choices are incorrect: B. Grandeur:
Grandiosity involves an inflated sense of self-importance, power, or identity. It's not evident in this scenario, as the client isn't expressing beliefs of exceptional abilities or status. C. Somatic delusion:
Somatic delusions focus on bodily functions or sensations, such as believing organs are rotting or insects are crawling under the skin. The client's outburst isn't related to bodily concerns. D. Erotomania:
Erotomania is a delusion where a person believes someone of higher status is in love with them. It's not applicable in this situation as the client's belief isn't about romantic interest.
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