The client’s lithium level is 1.8 mEq/L. The first appropriate nursing action is to:

Observe the client for signs of toxicity

Document the laboratory results in the medical record

Notify the client’s physician immediately

Hold the next dose of lithium

Answer and Explanation

The Correct Answer is C

Choice A reason: Observing for toxicity is important, but a lithium level of 1.8 mEq/L, above the therapeutic range (0.6–1.5 mEq/L), requires immediate action. Observation alone delays critical intervention, as symptoms like confusion or ataxia may already be present, necessitating urgent medical evaluation.

Choice B reason: Documenting results is necessary but not the first action. A lithium level of 1.8 mEq/L indicates potential toxicity, requiring immediate physician notification to adjust dosing or provide treatment, as delays could worsen neurological or renal complications.

Choice C reason: A lithium level of 1.8 mEq/L is above the therapeutic range, indicating early toxicity, which can cause neurological and renal damage. Notifying the physician immediately ensures prompt dose adjustment or discontinuation, preventing progression to severe toxicity, making this the priority action.

Choice D reason: Holding the next dose without physician guidance is risky, as abrupt cessation may destabilize mood in bipolar disorder. A level of 1.8 mEq/L requires medical evaluation to determine safe dose adjustments, making physician notification the first step.

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Correct Answer is C

Explanation

Choice A reason: Drawing blood for lab studies, such as BNP or electrolytes, is important in heart failure to assess severity and guide treatment. However, 2+ pitting edema and left ventricular enlargement suggest acute pulmonary congestion, making respiratory assessment the priority to detect life-threatening complications like pulmonary edema.

Choice B reason: Weighing the client monitors fluid status in heart failure, as weight gain indicates fluid retention. While important, it is secondary to assessing respiratory status, as edema and ventricular enlargement suggest possible pulmonary edema, which poses an immediate threat to oxygenation.

Choice C reason: Left ventricular enlargement and 2+ pitting edema indicate left-sided heart failure, which can lead to pulmonary edema, causing dyspnea and hypoxia. Assessing respiratory status first ensures detection of crackles or respiratory distress, enabling prompt intervention to prevent respiratory failure or worsening heart failure.

Choice D reason: Inserting a Foley catheter monitors urine output in heart failure but is not the first action. Respiratory distress from pulmonary edema, suggested by edema and ventricular enlargement, is a more immediate concern, requiring assessment of breathing to ensure adequate oxygenation and safety.

A. Experience anxiety without feeling overwhelmed B. Suppress anxious feelings C. Confront the source of anxiety directly D. Report absence of all anxiety symptoms

Correct Answer is A

Explanation

Choice A reason: Relaxation techniques, such as deep breathing or progressive muscle relaxation, modulate the autonomic nervous system, reducing sympathetic arousal. This allows the client to experience anxiety without overwhelming physiological or emotional responses, promoting better coping and emotional regulation, which is a realistic and therapeutic goal.

Choice B reason: Suppressing anxious feelings is not a realistic goal, as anxiety is a natural response. Relaxation techniques aim to manage, not eliminate, anxiety by reducing its intensity. Suppression can lead to emotional avoidance, potentially worsening underlying psychological conditions and hindering effective coping strategies.

Choice C reason: Confronting the source of anxiety directly is a goal of cognitive-behavioral therapy, not relaxation techniques. These techniques focus on physiological calming rather than addressing root causes, which requires structured therapeutic intervention, making this an inappropriate goal for relaxation training.

Choice D reason: Reporting the absence of all anxiety symptoms is unrealistic, as anxiety is a normal human emotion. Relaxation techniques aim to reduce the intensity and impact of anxiety, not eliminate it entirely, making this goal unattainable and less relevant for clients learning these methods.

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The client’s lithium level is 1.8 mEq/L. The first appropriate nursing action is to:

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Naxlex Comprehensive Predictor Exams

A nurse is admitting a new client to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first?

Correct Answer is C

Explanation

The best goal for a client learning a relaxation technique is that the client will

Correct Answer is A

Explanation

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