A client with bipolar disorder is prescribed lithium. What should the nurse teach the client about lithium toxicity?

Correct Answer: D

Rationale: In this scenario, option D is correct because avoiding nonsteroidal anti-inflammatory drugs (NSAIDs) while on lithium is crucial to prevent lithium toxicity. NSAIDs can increase lithium levels in the blood, leading to toxicity. Option A is incorrect because taking lithium with meals does not specifically relate to lithium toxicity. Option B, while important for general monitoring of side effects, does not address the direct risk of lithium toxicity. Option C is partially correct as monitoring lithium levels and staying hydrated are important, but it does not address the specific interaction with NSAIDs that can lead to toxicity. Educationally, it is essential for nurses to understand the specific pharmacological interactions of medications like lithium to provide safe and effective care to clients with bipolar disorder. Teaching clients about potential drug interactions and toxicities empowers them to manage their medication regimen effectively and prevent harmful consequences.

Correct Answer: D

Rationale: The correct answer is D) Notify the healthcare provider immediately and hold the next dose of warfarin. Rationale: - Warfarin is an anticoagulant medication used to prevent blood clots. An elevated INR indicates that the blood is taking longer to clot, putting the client at risk for bleeding complications. - In this situation, the nurse's priority is to ensure the client's safety by notifying the healthcare provider promptly. Holding the next dose of warfarin can help prevent further elevation of the INR and reduce the risk of bleeding. - Administering vitamin K to reverse the effects of warfarin is not the initial action to take as it may interfere with the client's anticoagulation therapy. - Monitoring the client for signs of bleeding is important, but it is not the priority over taking immediate action to address the elevated INR. - Increasing the client's warfarin dosage when the INR is already elevated can further potentiate the risk of bleeding and is contraindicated. Educational context: Understanding the management of anticoagulation therapy is crucial for nurses caring for clients with conditions like atrial fibrillation. Recognizing the significance of monitoring INR levels and taking appropriate actions in response to abnormalities is essential to prevent complications and ensure patient safety. Nurses must be able to prioritize interventions based on the client's condition and medication regimen to provide effective and safe care.

Correct Answer: B

Rationale: Hyperventilation from anxiety or fear causes an excessive loss of CO2, leading to respiratory alkalosis. This shift in pH results from the rapid, shallow breathing that reduces the level of carbon dioxide in the blood. Respiratory acidosis would occur in cases of poor ventilation or CO2 retention, while metabolic acidosis/alkalosis relates to disturbances in bicarbonate, not breathing patterns.

Correct Answer: D

Rationale: In caring for a child with tetanus, the nurse should include minimizing the amount of stimuli in the room as an essential intervention. Tetanus, also known as lockjaw, is a condition caused by the toxin produced by the bacteria Clostridium tetani. This toxin affects the nervous system, leading to muscle stiffness and spasms. Minimizing stimuli in the room, such as noise and bright lights, can help reduce the frequency and severity of muscle spasms, which are characteristic of tetanus. Option A, ensuring proper hydration, is important for overall health but does not directly address the symptoms of tetanus. Administering prescribed antibiotics (Option B) is not the primary treatment for tetanus; instead, tetanus immune globulin is typically used. While monitoring vital signs (Option C) is important in any patient care setting, it is not the most critical intervention for managing tetanus in this scenario. Educationally, understanding the rationale behind each intervention helps nurses prioritize and provide appropriate care for patients with tetanus. By selecting the correct intervention, nurses can effectively manage the symptoms of tetanus and promote better outcomes for the child. This question highlights the importance of tailored interventions based on the specific needs of patients with different conditions.

Correct Answer: C

Rationale: In preparing a client for a bronchoscopy, the highest priority intervention is option C: Instruct the client to write down the questions. This is essential because it allows the client to organize their thoughts, address their concerns, and feel more empowered and in control of the situation. By writing down questions, the client is more likely to remember them and can effectively communicate with healthcare providers during the pre-procedure preparation. Option A, providing detailed education about the procedure, is important but may not address the immediate anxiety and questions of the client. Option B, administering anti-anxiety medication, should not be the first line of intervention as it does not address the root cause of the anxiety and should only be used if necessary. Option D, reassuring the client about the safety of the procedure, is important but may not directly address the client's immediate concerns and questions. In an educational context, this rationale emphasizes the importance of effective communication and empowering clients to take an active role in their care. Encouraging clients to write down their questions promotes patient-centered care and helps healthcare providers address individual needs and concerns, leading to better outcomes and patient satisfaction.