The nurse is caring for a client after an endoscopy. The client is lethargic and not responding to verbal commands. The priority nursing action is to:

assess the client's airway and breathing.

assess the client's gag reflex.

call the physician immediately.

document this as normal findings and reassess in half an hour.

Answer and Explanation

The Correct Answer is A

A. The client's lethargy and lack of response to verbal commands raise concerns about their level of consciousness and potential airway compromise. Assessing the client's airway and breathing involves ensuring that the airway is clear, assessing respiratory rate and effort, and monitoring oxygenation.
B. Assessing the gag reflex can provide additional information about airway protection. However, it should not delay assessment and intervention for airway and breathing concerns.
C. Contacting the physician may be necessary but it is not the priority nursing action in this situation. The nurse should first assess the client's airway and breathing to ensure their safety and stability.
D. The client's lethargy and unresponsiveness are not normal findings after an endoscopy and require immediate assessment and intervention. Delaying assessment and intervention could lead to serious complications, including respiratory compromise or airway obstruction.

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Correct Answer is A

Explanation

A. Lithium carbonate is a medication commonly used to treat bipolar disorder. Symptoms of lithium toxicity can include nausea, vomiting, diarrhea, muscle weakness, tremors, and flu-like symptoms. If a client is experiencing these symptoms after taking lithium carbonate, it could indicate lithium toxicity
B. Lithium is a mood stabilizer, and tolerance, in the sense of needing increasing doses to achieve the same effect, is not commonly observed.
C. Suddenly stopping lithium carbonate can lead to withdrawal symptoms, but the symptoms described— nausea, diarrhea, muscle weakness, and tremors—are more indicative of toxicity rather than withdrawal.
D. Tyramine is a compound found in certain foods and beverages, and interactions between tyramine-rich foods and certain medications, such as monoamine oxidase inhibitors (MAOIs), can lead to hypertensive crises. However, lithium carbonate is not known to have interactions with tyramine-rich foods.

A. client may have decided to carry out the suicide plan. B. medication has potentiated serotonin syndrome. C. medication dosage should be decreased. D. client's behavioral change is normal and expected.

Correct Answer is D

Explanation

D. This recognizes that the client's improvement in mood is a typical response to antidepressant medication and does not automatically suggest any negative outcomes such as suicidal ideation or serotonin syndrome.
A. It's important to be vigilant for signs of suicidal ideation but sudden improvements in mood can also occur as a positive response to antidepressant medication.
B. The client's description of feeling better does not align with the symptoms of serotonin syndrome, which include agitation, confusion, rapid heart rate, high blood pressure, and hyperthermia.
C. Antidepressant medications often take several weeks to reach their full therapeutic effect, so it's not unusual for some clients to experience an improvement in mood within the first few weeks of treatment.

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The nurse is caring for a client after an endoscopy. The client is lethargic and not responding to verbal commands. The priority nursing action is to:

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Naxlex Comprehensive Predictor Exams

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