The nurse is completing a plan of care for a client on lithium therapy to manage bipolar symptoms. Which nursing intervention(s) will be included? Select all that apply.

Monitor kidney and liver functioning.

Increase fluid intake to 3000 mL/day.

Monitor intake and output.

Limit sodium intake daily.

Instruct client that it may take up to 6 weeks to reach therapeutic level.

Monitor for symptoms of nausea, vomiting, muscle weakness, and lack of coordination.

Answer and Explanation

Correct Answer : A,B,C,F

A. Monitor kidney and liver functioning: Lithium is excreted by the kidneys and can cause nephrotoxicity with long-term use. Monitoring kidney function is essential to detect early signs of renal impairment. Liver monitoring may be less emphasized but is often included in general lab panels.
B. Increase fluid intake to 3000 mL/day: Adequate hydration helps maintain stable lithium levels and reduces the risk of toxicity. Dehydration can lead to lithium retention and increase serum concentrations to dangerous levels.
C. Monitor intake and output: Close tracking of fluid balance helps identify dehydration or fluid overload, both of which can impact lithium levels. Intake and output records also support safe dosing and prevent renal complications.
D. Limit sodium intake daily: Sudden sodium restriction can increase lithium reabsorption in the kidneys, raising the risk of toxicity. Consistency in sodium intake is recommended rather than limiting it unnecessarily.
E. Instruct client that it may take up to 6 weeks to reach therapeutic level: Lithium typically reaches steady-state levels in 5–7 days, and clinical improvement often occurs within 1–3 weeks. Six weeks is longer than expected and may delay appropriate follow-up or adjustment.
F. Monitor for symptoms of nausea, vomiting, muscle weakness, and lack of coordination: These are early signs of lithium toxicity and require immediate assessment. Prompt detection prevents progression to more severe neurological and renal complications.

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Correct Answer is C

Explanation

A. Dyspnea when ambulating from the bathroom: Mild exertional dyspnea is common in cardiac clients and may not require immediate provider notification unless it worsens or becomes unrelieved with rest.
B. A noted irregular pulse rate prior to Lanoxin (digoxin) administration: An irregular pulse may warrant holding the medication and further assessment, but it is not always an emergency unless associated with hemodynamic instability or bradycardia.
C. Pulsus paradoxus on vital sign assessment: Pulsus paradoxus, a significant drop in systolic blood pressure during inspiration, may indicate cardiac tamponade or severe pericardial effusion. It is a critical finding that requires immediate medical attention.
D. Cyanosis with a pulse oximetry level of 92%: While cyanosis is concerning, a SpO₂ of 92% may be acceptable for some cardiac or pulmonary patients. Further monitoring is needed, but it may not require urgent notification unless oxygen levels drop further.

A. Do not overuse the medication as rebound congestion can occur. B. Report white patches in the mouth because the medication can cause a fungal infection. C. Taper the dose when discontinuing the medication. D. Do not operate machinery or drive while using the medication.

Correct Answer is A

Explanation

A. Do not overuse the medication as rebound congestion can occur: Oxymetazoline is a topical nasal decongestant that can cause rebound congestion (rhinitis medicamentosa) if used for more than 3 consecutive days. The nasal passages become more congested once the medication wears off, leading to a cycle of dependency.
B. Report white patches in the mouth because the medication can cause a fungal infection: This instruction is more appropriate for inhaled corticosteroids, which can lead to oral thrush. Oxymetazoline does not carry a significant risk for oral fungal infections.
C. Taper the dose when discontinuing the medication: Tapering is generally used for systemic corticosteroids or certain long-term medications. Oxymetazoline should be stopped after short-term use rather than tapered, to prevent rebound symptoms.
D. Do not operate machinery or drive while using the medication: Oxymetazoline typically causes minimal systemic effects and is unlikely to impair mental alertness or motor function. It does not carry significant sedative properties.

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The nurse is completing a plan of care for a client on lithium therapy to manage bipolar symptoms. Which nursing intervention(s) will be included? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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