Which dietary recommendations would the nurse make to the patient who is taking lithium?

1-A nurse has completed teaching a client who is being discharged on lithium for a bipolar disorder. Which statement by the client indicates a need for further teaching? 1. "I need to drink 1-2 liters of fluid daily."

1. "I need to have my blood levels checked periodically."

2. "I should not limit my sodium intake."

4. "I should use ibuprofen for pain relief."

Explanation:

Lithium is a mood stabilizer most often used to treat bipolar affective disorders. It has a very narrow therapeutic serum range of 0.6-1 mEq/L (0.6-1 mmol/L). Levels >1 mEq/L (1 mmol/L) are considered toxic. Lithium toxicity usually occurs with the following:

1. Dehydration
2. Decreased renal function (eg, elderly clients)
3. Diet low in sodium
4. Drug-drug interactions (nonsteroidal anti-inflammatory drugs [NSAIDs] and thiazide diuretics)

Lithium is cleared renally. Even a mild change in kidney function (as seen in elderly clients) can cause serious lithium toxicity. Therefore, drugs that decrease renal blood flow (eg, NSAIDs) should be avoided. Acetaminophen would be a better choice for pain relief (Option 4). (Options 1 and 3) Sodium, water, and lithium are normally filtered by the kidneys. Restriction of dietary sodium/water or dehydration signals renal sodium and water reabsorption which will also increase lithium absorption, resulting in toxicity. Therefore, clients should never restrict their sodium or water intake while taking lithium; instead, they should maintain a consistent sodium intake. (Option 2) Blood should be drawn frequently to monitor for therapeutic lithium levels and toxicity. Educational objective: Dehydration, decreased renal function, diet low in sodium, and drug-drug interactions (eg, NSAIDs and thiazide diuretics) can cause lithium toxicity.

2-A client with cancer pain is prescribed oxycodone. Which teaching is most essential to help prevent long-term complications? 1. Teach the client how to assess blood pressure daily

2. Teach the client how to prevent constipation

1. Teach the client how to prevent itching

2. Teach the client how to prevent nausea

Explanation:

Oxycodone is a morphine-like opioid medication. Opioid medications bind to opioid receptors in the intestine, which slows peristalsis and increases water absorption, leading to constipation. Constipation is an almost universally expected side effect from opioid medications. Clients will not develop tolerance to this side effect. Although clients with idiopathic chronic constipation are not commonly advised to take laxatives, opioid-induced constipation is treated with simultaneous use of senna (stimulant) and docusate (stool softener). (Options 1 and 3) Opioids cause the release of histamine, a vasodilator, which is responsible for pruritus and flushing. Opioids can also cause peripheral vasodilation and nervous system depression; both can lead to hypotension. These develop in some clients when the treatment is initiated but usually resolve over time. Antihistamines (eg, diphenhydramine) can prevent the pruritus. Lifestyle changes (eg, rising slowly from a seated position) and adequate hydration can prevent hypotension. (Option 4) Opioids stimulate the opioid receptors in the gastrointestinal tract and the chemoreceptor trigger zone in the brain, producing nausea. This is also not seen with long-term use. Antiemetics (eg, ondansetron) can be helpful. Educational objective: Constipation is an expected long-term side effect of opioid use; clients will not develop tolerance to this side effect. It is important to teach aggressive preventive measures (eg, defecate when the urge is felt, drink 2-3 L of fluid/day, high-fiber diet, exercise) and simultaneous use of a stool softener and a stimulant.

3-The nurse is reviewing prescriptions for the assigned clients. Which prescriptions should the nurse question? Select all that apply. 1. Allopurinol for a client who developed tumor lysis syndrome from chemotherapy for acute leukemia 2. Dicyclomine for a client with a history of irritable bowel syndrome who develops a postoperative paralytic ileus 3. IV morphine for a client with severe acute renal colic pain who is scheduled for a percutaneous nephrolithotripsy 4. Levofloxacin for a client with a urinary tract infection who has a history of anaphylaxis to penicillin drugs 5. Simvastatin for a client with hypercholesterolemia who is reporting generalized muscle aches and weakness

Explanation:

The nurse should question these prescriptions and contact the health care provider:

(Option 2) This client has 1 risk factor, surgery within 24 hours. His addiction to heroin gives him a higher tolerance for opioids. (Option 3) This client has 1 risk factor, sleep apnea. Educational objective: Factors that increase risk for respiratory depression related to opioid use for pain control include advanced age, underlying pulmonary disease, snoring, obesity, smoking, opiate naïve, and surgery.

5-Which herbal supplements pose an increased risk for bleeding in surgical clients and should be discontinued prior to major surgery? Select all that apply. 1. Black cohosh

2. Garlic

3. Ginger

4. Ginkgo biloba

1. Hawthorne

Explanation:

Clients are often aware of the need to discontinue prescription medications such as aspirin and anticoagulants prior to elective surgery, but they may not know that some herbal supplements can increase bleeding risk. The nurse should question the client specifically about the use of herbal supplements. Herbal supplements that can increase risk for bleeding include:

 Gingko biloba  Garlic  Ginseng  Ginger  Feverfew

(Option 1) Black cohosh is used for treatment of menopausal symptoms. The main side effect is liver injury. (Option 5) Hawthorne extract is used to control hypertension and mild to moderate heart failure. Hawthorne use does not increase the risk of bleeding. Educational objective: Use of herbal supplements such as ginkgo biloba, garlic, ginseng, ginger, and feverfew should be reported to the health care provider before surgery as they may increase the risk of bleeding. 6-The health care provider prescribes phenazopyridine hydrochloride for a client with a urinary tract infection. What would the office nurse teach the client to expect while taking this medication?

1. Constipation

2. Difficulty sleeping

3. Discoloration of urine

1. Dry mouth

Explanation:

Phenazopyridine hydrochloride (Pyridium) is a urinary analgesic prescribed to relieve the pain and burning associated with a urinary tract infection. The urine will turn bright red-orange while on this medication; other body fluids can be discolored as well. Because staining of underwear, clothing, bedding, and contact lenses can occur, the nurse should suggest that the client use sanitary napkins and wear eyeglasses while taking the medication. Phenazopyridine hydrochloride provides symptomatic relief but no antibiotic action, and so it is important that the client take a full course of antibiotics. (Options 1, 2, and 4) Constipation, difficulty sleeping, and dry mouth are not common adverse effects of phenazopyridine hydrochloride. Educational objective: Phenazopyridine hydrochloride (Pyridium) is a urinary analgesic prescribed to relieve symptoms of dysuria associated with a urinary tract infection. An expected side effect of the drug is orange-red discoloration of urine.

7-A client is receiving IV sodium bicarbonate for acute metabolic acidosis. Which of these laboratory values would best indicate that the sodium bicarbonate has been effective? 1. Serum pH 7, HCO 3 - 26 mEq/L (26 mmol/L), potassium 4 mEq/L (4 mmol/L)

1. Serum pH 7, HCO 3 - 21 mEq/L (21 mmol/L), potassium 5 mEq/L (5 mmol/L)

3. Serum pH 7, HCO 3 - 24 mEq/L (24 mmol/L), potassium 3 mEq/L (3 mmol/L)

1. Serum pH 7, HCO 3 - 18 mEq/L (18 mmol/L), potassium 4 mEq/L (4 mmol/L)

Explanation:

Educational objective: Metabolic acidosis is an acid-base imbalance that occurs when the pH level drops from excess acid accumulation or bicarbonate (HCO 3 - ) loss. Interventions focus on treating the underlying cause and administering IV HCO 3 -.

8-The nurse in an outpatient clinic cares for a client with primary adrenal insufficiency (Addison's disease) who has been taking hydrocortisone 20 mg/day for the last 8 years. Which client data is most important to report to the primary healthcare provider (PHCP)? 1. Development of moon face

1. Heart rate increase from 75 to 84/min

3. Low-grade fever of 100 F (37 C)

1. Weight gain of 6 lb (2 kg) in 3 months

Explanation:

Corticosteroid therapy is the primary classification of drugs used to treat Addison's disease, an adrenocortical insufficiency. Signs and symptoms of infection should be reported to the PHCP immediately. Use of corticosteroids can cause immunosuppression. Infection can develop quickly and spread rapidly. Its anti-inflammatory effects may also mask signs of infection such as inflammation, redness, tenderness, heat, fever, and edema. In addition, physiological stress such as infection can trigger addisonian crisis, a life-threatening complication of Addison's disease. (Options 1, 2, and 4) Tachycardia, moon face, and weight gain are also side effects of long-term corticosteroid therapy; however, they are not as life-threatening as infection. Educational objective: In a client taking corticosteroids, it is imperative to notify the PHCP if signs and symptoms of infection, even a low-grade fever, occur. This is because the anti-inflammatory properties of these drugs can mask infection that can spread quickly in this type of immunocompromised client.

9-The nurse completes the following drug administrations. Which would require an incident report? 1. Client with chronic stable angina and blood pressure of 84/52 mm Hg; isosorbide mononitrate held 2. Client with depression stopped phenelzine yesterday; escitalopram given today 3. Client with diabetes and morning glucose of 90 mg/dL (5 mmol/L); the daily NPH insulin 20 units given at 8:00 AM 4. Client with pulmonary embolism and International Normalized Ratio (INR) of 2; warfarin given

Explanation:

Selective serotonin reuptake inhibitors (SSRIs) (eg, escitalopram) cannot be combined with monoamine oxidase inhibitors (MAOIs) (eg, phenelzine) as there is a risk of serotonin syndrome. MAOI effects persist long after dosing stops. An MAOI should be withdrawn at least 14 days before starting an SSRI. (Option 1) The isosorbide has actions identical to nitroglycerin and can cause hypotension from vasodilation. It should be held when the systolic blood pressure is <90 mm Hg. Perfusion to the kidneys is inadequate if the systolic blood pressure is <80 mm Hg. Because the pressure is so low, the nurse does not want to lower it further by giving the drug. (Option 3) Insulin is given to control diabetes. A "normal" fasting glucose level (70-99 mg/dL [3-5. mmol/L]) indicates that the dosing is correct and should be given to continue control of blood glucose. (Option 4) The effect of warfarin (Coumadin) is monitored by the INR. The therapeutic range of INR is 2-3. This result indicates that the current dosing is achieving the desired effect. Educational objective: There must be a minimum of 14 days between the administration of MAOIs and SSRIs to avoid serotonin syndrome; these medications cannot be administered concurrently.

10-The emergency department nurse prepares a male client for surgery. The client was admitted with a traumatic open fracture of the femur, hematocrit of 36% (0), and hemoglobin of 12 g/dL ( g/L). Which prescription should the nurse validate with the health care provider before administration? 1. Cefazolin

2. Enoxaparin

1. Morphine

2. Tetanus toxoid

Explanation:

The Joint Commission Surgical Improvement Project CORE measure set has shown that preventives (eg, heparin, enoxaparin, aspirin) in select surgical procedures, given 24 hours before and after surgery, reduce the risk of venous thromboembolism. However, the estimated blood loss in a client with a fracture can be significant depending on the site (eg, 250-1200 mL). Although this client's admission hematocrit (36% [0]) and hemoglobin (12 g/dL [120 g/L]) are only slightly low for an adult male (normal: 39%-50% [0.39-0], 13.2-17 g/dL [132-173 g/L]), the blood loss may not yet be evident. Therefore, the nurse would validate the prescription for enoxaparin (Lovenox) with the health care provider before administration. Medications commonly prescribed for a client with an open fracture include:

acceptance of changes due to the illness. However, this does not pose the greatest risk to the client's survival and is not the priority ND. (Option 2) Hopelessness related to activity restriction and worsening physiological status secondary to chronic RA is an appropriate ND. Interventions should focus on setting short-term goals to change behaviors and promoting a more positive attitude. However, this is not the priority ND. (Option 3) Impaired physical mobility related to decreased physical endurance and joint stiffness secondary to chronic RA is an appropriate ND. Interventions should focus on improving joint function and resuming the client's usual activities. However, this is not the priority ND. Educational objective: TNF inhibitors (eg, etanercept, infliximab, adalimumab) interfere with the body's normal immune response and cause immunosuppression. This increases the risk for a new infection or reactivation of a previous infection (eg, latent tuberculosis, hepatitis B virus ).

12-A 64-year-old client is prescribed ciprofloxacin for a urinary tract infection (UTI). The nurse instructs the client to observe for and notify the health care provider (HCP) immediately about which of the following? 1. Brown-colored urine

1. Hearing and balance problems

3. Pain in the Achilles tendon area

1. Sunburn

Explanation:

Use of fluoroquinolones (cipro floxacin , levo floxacin , moxi floxacin , norfloxacin, ofloxacin), especially ciprofloxacin, places clients at increased risk for tendinitis and tendon rupture that most often occur in the Achilles tendon. This class of antibiotics carries a black box warning about this risk. The Food and Drug Administration recommends that at the first sign of tendon pain or swelling, clients should stop taking the fluoroquinolone, abstain from moving the affected area, and contact their HCP promptly for further evaluation and a change of antibiotic. (Option 1) Turning urine into a harmless brown color is a common side effect of nitrofurantoin, another antibiotic commonly used for UTI treatment. (Option 2) Hearing and balance problems (vertigo) result from aminoglycoside ototoxicity (eg, gentamicin). (Option 4) Ciprofloxacin can cause photosensitivity. The client should be instructed to avoid sun exposure and use sunscreen while taking the medication.

Educational objective: Fluoroquinolones (ciprofloxacin) carry a black box warning citing an increased risk of tendinitis and rupture, especially of the Achilles tendon.

Exhibit 13-The nurse is preparing to administer medications due at 1800 to a client who had an aortic valve replacement 5 days ago. The client also has a urinary tract infection and hypercholesterolemia. Which action should the nurse implement first? Click on the exhibit button for additional information. 1. Assess the client's complete blood count and potassium (K+) level

2. Check the client's international normalized ratio (INR)

1. Measure the client's vital signs

2. Verify the client's name and date of birth

Explanation:

Warfarin is given as an anticoagulant to the client with a mechanical valve replacement. INR should be checked regularly to determine proper dosage and adequacy of therapy. An INR of 2- 3 is considered therapeutic for a client with a mechanical valve. The nurse should not administer warfarin without checking the INR first. Warfarin should be administered if the INR is ≤3. If the INR is >3 , the nurse should hold the dose and contact the health care provider (HCP) for further direction. (Option 1) The CBC and K+ level should have been checked during administration of the 0900 doses of levofloxacin and potassium chloride. (Option 3) The client's vital signs should be measured routinely, but administration of warfarin and simvastatin are not contingent on the results. (Option 4) Verification of the client's name and date of birth should be done at the bedside, immediately before medication administration. Educational objective: The nurse should check the client's most recent INR level prior to administering warfarin. Therapeutic level is 2.5-3 for clients with mechanical heart valves. The nurse should hold the dose and contact the HCP if INR is >3.

Exhibit 14-A client with coronary artery disease and atrial fibrillation is being discharged home following coronary artery stent placement. Discharge medications are shown in the exhibit. The nurse

5. Prepare a second dose of naloxone

Explanation:

A client in the post-operative period that is unresponsive to painful stimuli is likely still under the effects of medications used during anesthesia. Using the opioid antagonist naloxone (Narcan) will temporarily reverse the effects of any opioid medications. Unfortunately, the half-life of naloxone is much shorter than most opioid medications, wearing off in 1–2 hours. The nurse should make repeat assessments of the post-surgical client's respiratory rate and administer prescribed oxygen for respiratory support. The health care provider should be notified and a second dose of naloxone should be prepared and administered as prescribed (either as a one-time dose or a continuous drip, depending on the prescription). (Option 3) An overly sedated client is not an indication for a rapid response team. Although this intervention is unlikely to cause harm to the client, it is not necessary and may result in overuse of personnel resources. If additional information indicates a more serious situation (eg, respiratory rate <8 breaths/min, oxygen saturation <90%), it may be appropriate to initiate the emergency response system. Educational objective: Naloxone (Narcan) is usually prescribed as needed for post-surgical clients for over-sedation related to opioid use. The nurse should continue to monitor clients who are given naloxone with the understanding that the opioid antagonist has a shorter half-life than most of the opioids it is meant to counteract. As a result, a second dose of naloxone may be necessary.

16-A client with a history of heart failure calls the clinic and reports a 3-lb (1-kg) weight gain over the past 2 days and increased ankle swelling. The nurse reviews the client's medications and anticipates the immediate need for dosage adjustment of which medication? 1. Bumetanide

1. Candesartan

2. Carvedilol

3. Isosorbide

Explanation:

Most clients with heart failure are prescribed a loop diuretic (eg, furosemide, torsemide, bumetanide ) to reduce fluid retention. If the client has signs and symptoms of excessive fluid accumulation, the nurse will need to assess the situation by asking the client about dietary and fluid intake, adherence to prescribed medications, and the presence of any other associated symptoms (eg, shortness of breath). If the client is stable, the nurse may anticipate the need to increase the dosage of the prescribed loop diuretic (eg, bumetanide).

(Option 2) Lo sartan , val sartan , and cande sartan (sartans) are the commonly used angiotensin II receptor blockers. They are used in clients who cannot take ACE inhibitors (eg, lisinopril, ramipril). They block the renin-angiotensin-aldosterone system but will not affect the fluid status of the client with acute heart failure. (Option 3) Metopro lol , bisopro lol , and carvedi lol ( lols ) are the commonly used beta blockers for treatment of chronic heart failure. They block the negative effects of the sympathetic nervous system (increased heart rate) and reduce the cardiac workload. However, they can worsen heart failure if used in the acute setting of this condition. (Option 4) Isosorbide (nitrate) and hydralazine are used in African American clients with heart failure; this combination decreases cardiac workload by reducing preload and afterload. However, it does not decrease excess fluid. Educational objective: A client who reports weight gain and edema requires evaluation for additional symptoms of fluid volume overload (eg, shortness of breath) and adherence to the current treatment plan. If the client is stable, an increase in the dosage of loop diuretic (eg, furosemide, torsemide, bumetanide) is anticipated.

17-A client with coronary artery disease and stable angina is being discharged home on sublingual nitroglycerin (NTG). The nurse has completed discharge teaching related to this medication. Which statement by the client indicates that the teaching has been effective? 1. "I can keep a few pills in a plastic bag in my pocket in case I need them while I'm out."

1. "I can still take this with my vardenafil prescription."

3. "I can take up to 3 pills in a 15-minute period if I am experiencing chest pain."

1. "I should stop taking the pills if I experience a headache."

Explanation:

Current evidence shows that up to 50% of clients lack knowledge about NTG administration procedures, storage, and side effects. Proper teaching can prevent many hospital visits for chest pain due to stable angina. Instructions for proper NTG administration include:

 Tablets are heat and light sensitive: They should be kept in a dark bottle and capped tightly. An opened bottle should be discarded after 6 months (Option 1).  Take up to 3 pills in a 15-minute period: Take 1 pill every 5 minutes (up to 3 doses). Emergency medical services (EMS) should be called if pain does not improve or worsens 5 minutes after the first tablet has been taken. Previously, clients were taught to call after the third dose was taken, but newer studies suggest this causes a significant delay in treatment (Option 3).

1. Avoid a high-potassium diet

2. Exercise regularly and maintain a high-fiber diet

3. Maintain oral hygiene

4. Report excessive urination and increased thirst

Explanation:

Lithium is a mood stabilizer most often used to treat bipolar affective disorders. It has a narrow therapeutic index (0.6-1 mEq/L [0.6-1 mmol/L]). Risk factors for lithium toxicity include d ehydration, d ecreased renal function (in the elderly), d iet low in sodium, and d rug-drug interactions (eg, nonsteroidal anti-inflammatory drugs [NSAIDS] and thiazide diuretics). Chronic toxicity can result in:

1. Neurologic manifestations – ataxia, confusion or agitation, and neuromuscular excitability (tremor, myoclonic jerks)
2. Nephrogenic diabetes insipidus – polyuria and polydipsia (increased thirst) (Option 4)

Clients should be educated about monitoring for these symptoms and obtaining serum lithium levels at regular intervals. (Option 1) Dietary potassium should be avoided when taking drugs such as potassium-sparing diuretics (eg, spironolactone, triamterene, amiloride) and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. (Option 2) Regular exercise and a high-fiber diet can prevent constipation, which is not a known side effect of lithium. Opioids, anticholinergics, and iron supplements are medications that cause constipation. (Option 3) Good oral hygiene is ideal for every client but is not specially indicated for those taking lithium. Clients taking phenytoin should maintain oral hygiene to prevent gingival hyperplasia. Educational objective: Risk factors for lithium toxicity include dehydration, decreased renal function, low-sodium diet, and drug-drug interactions (eg, NSAIDs and thiazide diuretics). Chronic toxicity manifests with neurologic symptoms (ataxia, confusion or agitation, and neuromuscular excitability) and/or diabetes insipidus (polyuria and polydipsia).

20-A newly admitted client describes symptoms of dizziness and feeling faint on standing. The client has a history of type 2 diabetes, coronary artery disease, and bipolar disorder. Which medications may be contributing to the client's symptoms? Select all that apply. 1. Atorvastatin

1. Metformin

3. Metoprolol

4. Olanzapine

1. Omeprazole

Explanation:

Drugs commonly associated with orthostatic hypotension include:

1. Most antihypertensive medications, particularly sympathetic blockers such as beta blockers (eg, metoprolol) and alpha blockers (eg, terazosin) (Option 3)
2. Antipsychotic medications (eg, olanzapine, risperidone) and antidepressants (eg, selective serotonin reuptake inhibitors) (Option 4)
3. Volume-depleting medications such as diuretics (eg, furosemide, hydrochlorothiazide)
4. Vasodilator medications (eg, nitroglycerine, hydralazine)
5. Narcotics (eg, morphine)

Clients at risk for developing orthostatic hypotension should be instructed to:

1. Take medications at bedtime, if approved by the health care provider
2. Rise slowly from a supine to standing position, in stages (especially in the morning)
3. Avoid activities that reduce venous return and worsen orthostatic hypotension (eg, straining, coughing, walking in hot weather)
4. Maintain adequate hydration

(Option 1) Muscle cramps and liver injury, not orthostatic hypotension, are the major adverse effects of statin medications (eg, atorvastatin). (Option 2) Major side effects of metformin are lactic acidosis and gastrointestinal disturbances (metallic taste in the mouth, nausea, and diarrhea). Unlike insulin, metformin does not usually cause hypoglycemia. Orthostatic hypotension is not a common side effect. (Option 5) Proton pump inhibitors (eg, omeprazole) are associated with increased risk of pneumonia, Clostridium difficile diarrhea, and calcium malabsorption (osteoporosis), but not orthostatic hypotension. Educational objective: Medications commonly associated with orthostatic hypotension include most antihypertensives, most antipsychotics and antidepressants, and volume-depleting agents. Clients are instructed to rise slowly when standing to prevent a drop in blood pressure.

Exhibit 21-The nurse working on the inpatient psychiatric unit is preparing to administer 9:00 AM medications to a client. The medication administration record is shown in the exhibit. On assessment, the client is

(Option 2) Due to the life-threatening nature of NMS, the HCP should be informed immediately. The HCP may order muscle enzymes, administer IV fluids/medications, and move the client for close monitoring (eg, to the ICU).

(Option 4) Hydrochlorothiazide is a diuretic commonly used for hypertension. It does not cause NMS symptoms.

Educational objective: NMS is characterized by fever, muscle rigidity, altered mental status, and autonomic dysfunction. The most important intervention is to discontinue the antipsychotic medication.

22-The home health nurse reviews the serum laboratory test results for a client with seizures. The phenytoin level is 27 mcg/mL. The client makes which statement that may indicate the presence of dose-related drug toxicity and prompt the nurse to notify the health care provider?

1. "I am feeling unsteady when I walk." 2. "I am getting up to urinate about 4 times during the night." 3. "I have a metallic taste in my mouth when I eat." 4. "My gums are getting so puffy and red."

Phenytoin (Dilantin) is an anticonvulsant drug used to treat generalized tonic-clonic seizures. The therapeutic serum phenytoin reference range is between 10-20 mcg/mL. Levels are measured when therapy is initiated, periodically throughout treatment to guide dosing until a steady state is attained (3-12 months), and if seizure activity increases.

Early signs of toxicity include horizontal nystagmus and gait unsteadiness. These may be followed by slurred speech, lethargy, confusion, and even coma. Bradyarrhythmias and hypotension are usually seen with intravenous phenytoin.

(Option 2) Nocturia is an expected side effect of diuretics but not phenytoin. Nocturia is also seen with diabetes mellitus and benign prostatic hyperplasia.

(Option 3) Metallic taste in the mouth is often seen with metronidazole but not with phenytoin.

(Option 4) Gingival hyperplasia is a common expected side effect of phenytoin and does not indicate drug toxicity. It occurs more often in clients <23 years of age who are prescribed >500 mg/day. Good oral hygiene can limit symptoms.

Educational objective: Phenytoin, an anticonvulsant drug, is used to treat generalized tonic-clonic seizures. Common symptoms of phenytoin drug-induced toxicity involve the central nervous system and include ataxia , nystagmus , slurred speech, and decreased alertness.

23-The clinic nurse evaluates a client who was prescribed lithium therapy a month ago for bipolar disorder. Which client statement would cause the most concern?

1. "Everyone in my family has had the stomach flu; I will probably get it too."

1. "I've felt the need for an afternoon nap most days this week."

2. "I've gained 3 pounds since I began taking this medication."

3. "My mouth seems to be dry all the time."

Explanation:

Lithium is often used in the treatment of bipolar disorder. It has expected, mild side effects as well as potentially serious ones related to drug toxicity. Drowsiness, weight gain, dry mouth, and gastrointestinal upset are expected, mild side effects. Lithium toxicity occurs with dehydration, low-sodium diet, decreased renal function , and drug- drug interactions (eg, NSAIDs, thiazide diuretics ). Lithium and sodium are closely related in the body. Clients with vomiting and diarrhea are at risk of developing dehydration and/or low serum sodium. (Option 2) Drowsiness is an expected side effect. The nurse should advise the client to avoid hazardous activities and driving until the drug's effects are known or this side effect subsides. (Option 3) Weight gain is an expected side effect. The nurse should provide client education about healthy food choices and proper exercise and/or provide for a dietary consult. (Option 4) Dry mouth is an expected side effect. The nurse should provide client teaching about measures to counteract this side effect (eg, ice chips, sugarless gum or candy, drinking plenty of water). However, excess urination and polydipsia indicate nephrogenic diabetes insipidus from lithium toxicity. Educational objective: Dehydration and sodium loss from vomiting and diarrhea can lead to toxic lithium levels in clients receiving lithium therapy.

24-A nurse is assessing a client with type 2 diabetes mellitus who was recently started on pioglitazone. Which client data obtained by the nurse is most important to bring to the attention of the health care provider? 1. Bilateral pitting edema in ankles

1. Blood pressure is 140/88 mm Hg

2. Most recent HbA1c is 6%

3. Retinal photocoagulation in right eye

Explanation:

Which instruction should the nurse give a client who is prescribed lithium carbonate?

Which of the following symptoms would indicate to the nurse that a client is experiencing lithium toxicity select all that apply?

Which electrolyte level should the nurse check before administering lithium?

In which area of the body is the majority of lithium absorbed?