Nokea
A patient receiving lithium should be assessed for which evidence of early toxicity?
- A. Pharyngitis, mydriasis, and dystonia
- B. Alopecia, purpura, and drowsiness
- C. Diarrhea, thirst, and vomiting
- D. Ascites, dyspnea, and edema
Correct Answer: C
Rationale: Diarrhea, thirst, and vomiting are early signs of lithium toxicity. Other options are unrelated to lithium therapy.
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A patient develops mania after discontinuing lithium. New prescriptions are written to resume lithium twice daily and begin olanzapine. This is the expected reaction to the addition of olanzapine to the medication regimen?
- A. Minimize the side effects of lithium.
- B. Bring hyperactivity under rapid control.
- C. Enhance the antimanic actions of lithium.
- D. Provide long-term control of hyperactivity.
Correct Answer: B
Rationale: Olanzapine has a rapid onset to control hyperactivity initially, as lithium requires time to reach therapeutic levels. It does not enhance lithium's effects or minimize side effects.
A patient experiencing acute mania has exhausted the staff members by noon. The patient has joked, manipulated, insulted, and been aggressive all morning. Staff members are feeling defensive and fatigued. Which is the best action?
- A. Confer with the health care provider regarding use of seclusion for this patient.
- B. Hold a staff meeting to discuss consistency and limit setting approaches.
- C. Conduct a meeting with all patients to discuss the behavior.
- D. Explain to the patient that the behavior is unacceptable.
Correct Answer: B
Rationale: A staff meeting promotes consistency and limit setting, reducing staff splitting and frustration. Seclusion is not warranted, and other options are less effective.
At a unit meeting, staff members discuss the decor for a special room for patients experiencing mania. What select is the best option?
- A. Extra-large window with a view of the street
- B. Neutral walls with pale, simple accessories
- C. Brightly colored walls and print drapes
- D. Deep colors for walls and upholstery
Correct Answer: B
Rationale: A nonstimulating environment with neutral decor reduces sensory overload for manic patients. Other options may overstimulate or pose safety risks.
A health teaching plan for a patient taking lithium should include which instructions?
- A. Maintain normal salt and fluids in the diet.
- B. Drink twice the usual daily amount of fluids.
- C. Double the lithium dose if diarrhea or vomiting occurs.
- D. Avoid eating aged cheese, processed meats, and red wine.
Correct Answer: A
Rationale: Maintaining normal salt and fluid intake prevents lithium toxicity. Other options are incorrect or unrelated to lithium therapy.
When a hyperactive patient experiencing acute mania is hospitalized, what initial nursing intervention is a priority?
- A. Allowing the patient to act out his or her feelings
- B. Setting limits on the patient's behavior as necessary
- C. Providing verbal instructions to the patient to remain calm
- D. Restraining the patient to reduce hyperactivity and aggression
Correct Answer: B
Rationale: Setting limits provides structure and support while the patient's control is tenuous, prioritizing safety. Other options may escalate behavior or are inappropriate initially.