A nurse is reviewing the laboratory results of a client who is prescribed lithium 300 mg three times daily. The client’s serum lithium level is 1.4 mEq/L. Which of the following actions should the nurse take?
Encourage the client to increase sodium intake.
Document the result and reassess in 4 hours.
Notify the provider and hold the next dose.
Continue administering the medication as prescribed.
The Correct Answer is C
Choice A reason: Sodium intake does affect lithium levels because lithium and sodium compete for reabsorption in the kidneys. However, increasing sodium intake is not the immediate intervention for a client with a lithium level of 1.4 mEq/L, which is above the therapeutic range (0.6–1.2 mEq/L). The priority is to prevent further administration and notify the provider.
Choice B reason: Simply documenting and reassessing later delays necessary intervention. Lithium toxicity can progress quickly, and waiting 4 hours without action risks worsening symptoms. This option does not address the immediate safety concern.
Choice C reason: A level of 1.4 mEq/L indicates early lithium toxicity. The nurse should hold the next dose to prevent further accumulation and notify the provider immediately. This action ensures timely medical evaluation and prevents progression to severe toxicity, which can cause neurological and cardiovascular complications.
Choice D reason: Continuing the medication as prescribed would worsen toxicity. Administering lithium at this level is unsafe and contraindicated. This option disregards the abnormal laboratory finding and places the client at risk.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: ECT is not the first-line treatment for depression. Antidepressant medications and psychotherapy are typically tried first.
Choice B reason: ECT is not a permanent cure for depression. It is highly effective but relapse can occur, requiring maintenance therapy.
Choice C reason: ECT is not primarily used for anxiety disorders. It is reserved for severe depression, catatonia, or treatment-resistant cases.
Choice D reason: ECT is particularly effective for patients with treatment-resistant depression, especially when symptoms are severe and life-threatening, such as suicidal ideation and significant weight loss. This makes it the most appropriate reason for choosing ECT in this case.
Correct Answer is A
Explanation
Choice A reason: The most therapeutic approach is to acknowledge the client’s distress and validate their concerns while gently redirecting focus toward coping strategies. This balances empathy with promoting adaptive behaviors. It avoids dismissing the client’s experience and supports long-term management of somatic symptom disorder.
Choice B reason: Encouraging the client to minimize attention to symptoms may appear dismissive and can increase anxiety or mistrust. Clients with somatic symptom disorder often feel invalidated, so this approach is not therapeutic.
Choice C reason: Immediate psychiatric evaluation is not warranted unless there is evidence of acute psychiatric crisis, such as suicidal ideation. In this case, the client’s symptoms are consistent with somatic symptom disorder and can be managed with therapeutic communication and coping strategies.
Choice D reason: Reassuring the client that nothing is physically wrong invalidates their experience and may worsen anxiety. It is not therapeutic and does not promote trust or coping.
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