Nokea
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.
- A. Monitor for symptoms of nausea, vomiting, muscle weakness, and lack of coordination.
- B. Increase fluid intake to 5000 mL/day.
- C. Limit sodium intake daily.
- D. Monitor kidney and liver functioning.
- E. Instruct client that it may take up to 6 weeks to reach therapeutic level.
- F. Monitor intake and output.
Correct Answer: A,B,D,F
Rationale: The nurse is correct to place in the plan of care interventions that include monitoring for symptoms of lithium toxicity, increasing fluid intake to maintain fluid balance, monitoring kidney and liver function, and monitoring intake and output. Salt intake is important to regulate lithium levels in the body. A therapeutic lithium level is accomplished in a few days to a week.
You may also like to solve these questions
Anticonvulsants enhance which neurotransmitter in clients diagnosed with bipolar disorder?
- A. Serotonin
- B. Dopamine
- C. GABA
- D. Acetylcholine
Correct Answer: C
Rationale: Anticonvulsants may achieve their therapeutic effects by enhancing the action of GABA in much the same way that benzodiazepines reduce anxiety. Anticonvulsants do not enhance serotonin, dopamine, or acetylcholine.
Which of the following nursing diagnoses is of highest priority when caring for a client who is depressed and considers suicide?
- A. Suicide Attempt Risk
- B. Injury Risk
- C. Sleep Deprivation
- D. Coping Impairment
Correct Answer: A
Rationale: Clients with a nursing diagnosis of Suicide Attempt Risk are at an increased risk for suicide due to their feeling of despair. Providing nursing interventions that recognize the client's mood and maintain safety is essential. The other nursing diagnoses are also important and may also be appropriate but are not of the highest priority.
The nurse is caring for a client with a disturbance in thought process who is disoriented and aggressive. What nursing action may produce further agitation?
- A. Speaking in slow, brief sentences
- B. Presenting the reality of the situation
- C. Allowing the client freedom in a confined area
- D. Being present without speaking
Correct Answer: B
Rationale: When caring for a client with a disturbed thought process, presenting the reality of a situation may create conflict and confusion. Also, this can lead to a verbal exchange and escalation in agitation by the client. Actions by the nurse include attempts to decrease tension and anxiety such as speaking in slow, brief sentences so the client can comprehend instructions. Allow the client freedom when maintaining a safe environment. Being present to support and assist the client without speaking is less likely to produce agitation.
What mood disorder has alternating sad and elated mood, resembling bipolar disorder, but less extreme mood shifts?
- A. Euthymia
- B. Dysthymia
- C. Cyclothymia
- D. Psychotic depression
Correct Answer: C
Rationale: Cyclothymia, alternating sad and elated moods, resembling bipolar disorder, but the extremes of mood are less pronounced. People with normal moods are referred to as euthymic. Dysthymia is a feeling of unremitting sadness and is similar to but less severe than major depression. Psychotic depression encompasses an extreme form of depressive disorder and some persons experience hallucinations and delusions.
The nurse is admitting a client to a mental health clinic following a recent suicide attempt and hospitalization. In assessing the client's status, which question is most helpful?
- A. How are you currently feeling?
- B. What made you decide to commit suicide?
- C. Do you have a suicide plan or thoughts of harming yourself?
- D. What method did you choose for your suicide attempt?
Correct Answer: C
Rationale: In assessing the client's status, it is best to evaluate suicide risk factors. A client who is at the highest risk for suicide is the client who verbalizes a desire to end life and has a plan. The other questions are relevant but not the best question for gaining essential information.