Which of the following nursing interventions should a nurse perform when caring for a female client with mood disorder who is prescribed lithium?
Instruct to resume regular activities such as driving.
Administer lithium before meals.
Withhold if serum level is less than 1.5 mEq.
Instruct to avoid breastfeeding.
The Correct Answer is D
A. Instruct to resume regular activities such as driving. It is not safe to instruct the client to resume activities like driving immediately, especially at the beginning of lithium therapy, as lithium can cause side effects that may impair the client's ability to safely perform tasks such as driving.
B. Administer lithium before meals. Lithium is typically taken with food to minimize gastrointestinal upset. Administering it before meals may increase the risk of side effects like nausea.
C. Withhold if serum level is less than 1.5 mEq. Lithium should be withheld if the serum level is above the therapeutic range (typically 0.6–1.2 mEq/L), as higher levels can lead to toxicity. Withholding lithium if the level is less than 1.5 mEq/L is incorrect and could lead to inadequate treatment.
D. Instruct to avoid breastfeeding. Lithium is excreted in breast milk and can pose a risk to the infant, so the client should be advised against breastfeeding while on lithium therapy.
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Correct Answer is D
Explanation
A. Instruct to resume regular activities such as driving. It is not safe to instruct the client to resume activities like driving immediately, especially at the beginning of lithium therapy, as lithium can cause side effects that may impair the client's ability to safely perform tasks such as driving.
B. Administer lithium before meals. Lithium is typically taken with food to minimize gastrointestinal upset. Administering it before meals may increase the risk of side effects like nausea.
C. Withhold if serum level is less than 1.5 mEq. Lithium should be withheld if the serum level is above the therapeutic range (typically 0.6–1.2 mEq/L), as higher levels can lead to toxicity. Withholding lithium if the level is less than 1.5 mEq/L is incorrect and could lead to inadequate treatment.
D. Instruct to avoid breastfeeding. Lithium is excreted in breast milk and can pose a risk to the infant, so the client should be advised against breastfeeding while on lithium therapy.
Correct Answer is A
Explanation
A. "I am not on vacation. I am here with you." This response calmly reassures the client by affirming the mother’s presence, which helps address the son’s confusion without directly challenging his perception.
B. "How can I go on vacation? I do not have any money." This response could increase confusion and does not address the son's needs effectively. It could also lead to unnecessary discussions that might not be helpful.
C. "Stop saying that. You know better. No one told you that." This response is dismissive and confrontational, which may exacerbate the son’s distress and could damage the therapeutic relationship.
D. "Just forget about that and let's talk about something else." This response avoids addressing the son’s concerns, which can make him feel dismissed and not listened to, potentially worsening his symptoms.
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