Practice Question
A nurse is caring for a client taking lithium for bipolar disorder. The client reports nausea, muscle weakness, and hand tremors. The nurse reviews the client laboratory results and notes a lithium level of 2.0 mEq/L. Which of the following is the nurse's priority action?
Answer Choices:
Correct Answer:
Withhold the next dose and notify the provider
Rationale:
⭐ A lithium level of 2.0 mEq/L is above the typical therapeutic range (0.6–1.2 mEq/L) and indicates lithium toxicity.
⭐ Symptoms such as nausea, muscle weakness, and hand tremors are classic early manifestations of lithium toxicity that require prompt action.
⭐ The priority intervention is to withhold the next dose to prevent further drug accumulation and notify the provider for urgent evaluation and possible additional orders (e.g., IV fluids, monitoring).
⭐ Continuing the medication could worsen toxicity and potentially lead to neurologic complications such as confusion, ataxia, or seizures.
⭐ This action aligns with safety-first nursing practice, preventing further harm while arranging definitive management.
Reassure the client that these are expected side effects
⭐ While mild fine hand tremor and some GI upset can occur with lithium, at a level of 2.0 mEq/L these findings are better interpreted as toxicity, not normal.
⭐ Providing reassurance would delay critical intervention, allowing lithium levels to remain elevated or increase further.
⭐ The nurse must recognize that lab data plus symptoms indicate a potential medical emergency, not a benign side effect profile.
⭐ Reassurance alone ignores the abnormal serum level, which is key objective evidence of toxicity.
⭐ Therefore, this option is unsafe and incorrect because it fails to address the priority: stop lithium and notify the provider.
Encourage the client to increase daily sodium intake
⭐ Sodium intake can influence lithium levels, and low sodium can increase lithium retention, but this is not the priority intervention when toxicity is already present.
⭐ Increasing sodium might help long-term stability, but it does not immediately reduce an already toxic level of lithium.
⭐ Focusing on diet at this moment delays urgent action—withholding the drug and notifying the provider.
⭐ The client requires acute management (possible IV hydration, monitoring) rather than a non-urgent dietary adjustment.
⭐ Thus, this option is incorrect because it does not address the immediate safety concern of active lithium toxicity.
Instruct the client to take the medication with food
⭐ Taking lithium with food can help reduce GI side effects, such as mild nausea, but it does not correct a serum level of 2.0 mEq/L.
⭐ The symptoms in this scenario are occurring in the presence of a toxic lithium level, which must be treated as toxicity, not simple GI intolerance.
⭐ Advising the client to continue lithium with food would encourage further ingestion, worsening the toxic state.
⭐ This response shows a failure to connect objective lab data with the client’s clinical presentation.
⭐ Therefore, it is incorrect and potentially dangerous, as it ignores the need to withhold the next dose and contact the provider.
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This question is from LPN Mental Health NSG 2320 Exam which contains 45 questions.
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Question Details
- Category: LPN Nursing Exam(s)
- Subcategory: 💎Examplify-PN
- Domain: 🤦🏼♀️ Mental Health-PN
- Answer Choices: 4