The nurse is caring for the following assigned clients. The nurse should initially follow-up on the client who
The nurse is caring for the following assigned clients. The nurse should initially follow-up on the client who
A. is taking lithium that reports nausea and vomiting.
[79%]
B. is refusing their prescribed quetiapine.
[5%]
C. is reporting a headache following the first dose of citalopram.
[11%]
D. gets drowsy following a dose of alprazolam.
[4%]
Statistics
Subject/Lesson
Subject
Leadership & Management
Lesson
Prioritization
Client Need
Test Plan
Pharmacological and Parenteral Therapies
Related Topic
Adverse Effects/Contraindications/Side Effects/Interactions
Item Type
Item Type
Application
Explanation
Choice A is correct. A client taking lithium needs to be monitored closely for nausea and vomiting. These are early manifestations of lithium toxicity. Lithium toxicity must be recognized promptly as it may lead to more severe symptoms.
Choice B is incorrect. A client refusing a medication should always be followed up on because the client needs to be counseled on the purpose of the medication and its effects. If the client continues to refuse medication the nurse should inquire as to why and notify the provider.
Choice C is incorrect. A headache following the administration of citalopram is a common side effect and warrants no immediate follow-up.
Choice D is incorrect. Drowsiness following the administration of a benzodiazepine is an expected finding. Drowsiness is the most common side-effect associated with a benzodiazepine.
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Additional Info
✓ Lithium levels should be maintained between 0.6 – 1.2 mEq/L (mmol/L.).
✓ Lithium requires the client to maintain adequate fluid and salt. Failing to do so for the client may result in lithium toxicity.
✓ Lab findings expected with lithium include leukocytosis and hypothyroidism (long-term use).
✓ The client should avoid medications such as diuretics, NSAIDs, and ACE inhibitors, as these medications may cause lithium toxicity.
✓ Lithium levels should be drawn twelve hours following the client's last dose. If not, this may falsely elevate the lithium level.
✓ Lithium toxicity signs and symptoms include nausea, vomiting, lethargy, confusion, delirium, coma, seizures, and hypotension.
