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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Weight gain is not a common side effect of buspirone, which affects serotonin and dopamine receptors to reduce anxiety. It is more associated with antidepressants like SSRIs or mirtazapine, which alter metabolism or appetite, making this incorrect.
Choice B reason: Buspirone commonly causes dizziness due to its effects on serotonin and dopamine pathways, which can alter blood pressure or central nervous system function. This side effect is significant, as it impacts safety and requires client awareness, making it a key teaching point.
Choice C reason: Dry skin is not a recognized side effect of buspirone. This medication primarily affects neurological and gastrointestinal systems, not dermatological conditions, making this an irrelevant and incorrect side effect to include in client education.
Choice D reason: Increased appetite is not typically associated with buspirone. While some psychotropic medications affect appetite, buspirone’s primary side effects include dizziness and nausea, not appetite changes, making this an incorrect focus for client education.
Correct Answer is B
Explanation
Choice A reason: Mild anxiety is characterized by slight restlessness or discomfort, with intact concentration and problem-solving abilities. The client’s symptoms, including rapid pacing, trembling, and inability to concentrate, indicate a more intense physiological and cognitive impairment, ruling out mild anxiety as the correct assessment.
Choice B reason: Panic-level anxiety involves extreme physiological arousal, with symptoms like rapid pacing, trembling, high-pitched speech, and inability to concentrate or problem-solve. These reflect a severe sympathetic nervous system response, overwhelming the client’s ability to function, making panic the most accurate description of the client’s state.
Choice C reason: Moderate anxiety involves noticeable discomfort, with some difficulty concentrating but retained problem-solving ability. The client’s severe symptoms, including high-pitched speech and restricted problem-solving, exceed this level, indicating a more intense state of anxiety that aligns with panic rather than moderate anxiety.
Choice D reason: Severe anxiety includes significant distress and impaired function but typically allows some concentration and problem-solving, unlike panic. The client’s extreme symptoms, such as inability to concentrate and restricted problem-solving, suggest a higher level of distress consistent with a panic state.
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