The nurse is continuing to care for the client.

Exhibits

The nurse is providing teaching about lithium to the client and the client's adult child.

Select the 3 statements the nurse should include.

"Blurred vision is an expected adverse effect of this medication,"

"This medication can cause weight gain."

"This medication can cause nausea and drowsiness."

"It will take at least a week before this medication reaches a therapeutic level."

"You will be placed on a low-sodium diet while taking this medication."

Answer and Explanation

Correct Answer : B,C,D

A. "Blurred vision is an expected adverse effect of this medication." Blurred vision is not a common or expected adverse effect of lithium. If this occurs, it may indicate toxicity or another underlying issue and should be reported. It is not part of routine education for expected side effects.
B. "This medication can cause weight gain." This is true. Weight gain is a known long-term adverse effect of lithium therapy and should be discussed with the client and family as part of monitoring and lifestyle considerations during treatment.
C. "This medication can cause nausea and drowsiness." These are common initial side effects when starting lithium and usually subside over time. Clients should be aware of these effects so they can differentiate between expected reactions and signs of toxicity.
D. "It will take at least a week before this medication reaches a therapeutic level." Correct. Lithium takes 7–14 days to reach therapeutic plasma levels, so clients may not experience symptom relief immediately. During this period, supportive care and safety monitoring are essential.
E. "You will be placed on a low-sodium diet while taking this medication." This is incorrect. Lithium has a narrow therapeutic index, and sodium levels affect lithium levels. A low-sodium diet can increase the risk of lithium toxicity, so clients should maintain a consistent sodium intake, not reduce it.

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Correct Answer is D

Explanation

A. Trochanter roll. This device is used to prevent external rotation of the hips, especially in clients who are immobile or lying supine. It does not support the feet or ankles and does not prevent plantar flexion.
B. Abduction pillow. An abduction pillow is placed between the legs to maintain proper hip alignment, particularly after hip surgery. It is not designed to prevent foot drop or plantar flexion contractures.
C. Sheepskin heel pad. This provides skin protection and pressure relief to prevent pressure ulcers on the heels. While useful for comfort and skin integrity, it does not keep the foot in a neutral position to prevent contractures.
D. Footboard. A footboard is placed at the foot of the bed to help maintain the foot in dorsiflexion, thereby preventing plantar flexion contractures (also known as foot drop). It supports proper alignment and is the most appropriate device for this purpose in clients with limited mobility.

A. Turn off oxygen sources. B. Put out the fire with an extinguisher. C. Close the fire doors on the unit. D. Notify the facility operator.

Correct Answer is A

Explanation

A. Turn off oxygen sources. After ensuring the client is safe, the priority is to reduce the risk of fire spreading, and oxygen greatly increases flammability. Turning off oxygen is a critical safety measure to prevent rapid combustion.
B. Put out the fire with an extinguisher. While extinguishing the fire is important, it should only be attempted if safe to do so and after addressing immediate dangers, such as oxygen sources and client safety.
C. Close the fire doors on the unit. This is part of containment under the RACE protocol (Rescue, Alarm, Contain, Extinguish), but it is not the first priority after rescue when oxygen is actively feeding the fire.
D. Notify the facility operator. This step corresponds to the "Alarm" phase of RACE and is essential for initiating the emergency response. However, it follows immediately after ensuring client safety and environmental hazard reduction, like turning off oxygen.

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The nurse is continuing to care for the client. Exhibits The nurse is providing teaching about lithium to the client and the client's adult child. Select the 3 statements the nurse should include.

Nursing Test Bank

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The nurse is continuing to care for the client.

Exhibits

The nurse is providing teaching about lithium to the client and the client's adult child.

Select the 3 statements the nurse should include.