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 A

Explanation

A. Respiratory rate 10/min. This is the priority finding because it suggests respiratory depression, a serious side effect of magnesium sulfate therapy. Magnesium acts as a CNS depressant, and a respiratory rate below 12/min is a potential sign of magnesium toxicity, which can lead to respiratory arrest if not promptly addressed.
B. 2+ deep-tendon reflexes. This indicates normal neuromuscular function and is actually a reassuring finding in a client receiving magnesium sulfate. Reflexes are typically monitored to detect early signs of toxicity, and a 2+ rating means the dose is likely therapeutic.
C. 3+ pedal edema. While significant, pedal edema is a common feature of preeclampsia and not directly related to magnesium sulfate toxicity. It should be monitored but does not require immediate action compared to respiratory compromise.
D. Urinary output 35 mL/hr. This is slightly above the minimum acceptable output of 30 mL/hr, indicating the kidneys are excreting adequately. While magnesium is excreted renally and output must be monitored, this value does not indicate an acute risk.

A. Place the client in a supine position B. Remind the client to eat scheduled meals daily. C. Offer the client a blanket to keep warm. D. Speak in a loud tone when addressing the client

Correct Answer is C

Explanation

A. Place the client in a supine position. As clients near the end of life, the supine position may compromise breathing. A semi-Fowler’s or lateral position is usually preferred to promote comfort and respiratory ease.
B. Remind the client to eat scheduled meals daily. At the end of life, appetite typically decreases, and forcing food can cause discomfort. Nutrition should be offered based on the client's desire, not forced on a strict schedule.
C. Offer the client a blanket to keep warm. Clients nearing death often experience peripheral circulation decline, leading to feelings of coldness. Providing a blanket promotes comfort and warmth without being invasive.
D. Speak in a loud tone when addressing the client. Loud speech can be disorienting and distressing, especially if the client is already weak or confused. Use a calm, clear, and gentle tone to provide comfort and maintain dignity.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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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.