A nurse is reviewing discharge instructions with a client who has bipolar disorder and is taking lithium. Which of the following manifestations should the nurse include as an indication of mild toxicity?

Muscle weakness.

Constipation.

Urinary retention.

Hyperactivity.

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Muscle weakness is a manifestation of mild lithium toxicity. Lithium toxicity can occur at therapeutic levels, so clients should be monitored for adverse effects.
Choice B rationale:
Constipation is not typically associated with lithium toxicity. Diarrhea, not constipation, is a symptom of lithium toxicity.
Choice C rationale:
Urinary retention is not a typical symptom of lithium toxicity. Increased urination and thirst are common side effects of lithium.
Choice D rationale:
Hyperactivity is not a typical symptom of lithium toxicity. Lithium is used to manage bipolar disorder and can help reduce hyperactivity.

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Correct Answer is D

Explanation

Choice A rationale:
Asking direct questions about the hallucination may validate the hallucination as real in the client’s mind.
Choice B rationale:
Instructing the client to argue with the voices could potentially increase the client’s distress.
Choice C rationale:
Acting as if the hallucination is real may reinforce the client’s belief in the hallucination.
Choice D rationale:
Telling the client that the hallucination is not a part of reality can help ground the client in reality.

A. "I know you hear the voices, but I do not.”. B. "The voices are part of your illness.”. C. "How often do you hear the voices?". D. "What are the voices telling you?".

Correct Answer is D

Explanation

Choice A rationale:

While acknowledging the voices can be part of therapeutic communication, it’s not the first response a nurse should make.

Choice B rationale:

Telling the client that the voices are part of their illness can be helpful, but it’s not the first response a nurse should make.

Choice C rationale:

Asking about the frequency of the voices can be part of the assessment, but it’s not the first response a nurse should make.

Choice D rationale:

Asking what the voices are saying can help assess if the client is experiencing command hallucinations, which could pose a safety risk.

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A nurse is reviewing discharge instructions with a client who has bipolar disorder and is taking lithium. Which of the following manifestations should the nurse include as an indication of mild toxicity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has schizophrenia and is experiencing a hallucination. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following responses should the nurse make first?

Correct Answer is D

Explanation

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