A male patient calls to tell the nurse that his monthly lithium level is 1.7 mEq/L. Which nursing intervention will the nurse implement initially?

Correct Answer: B

Rationale: The correct answer is B because a lithium level of 1.7 mEq/L is above the therapeutic range (0.6-1.2 mEq/L), indicating potential toxicity. Instructing the patient to hold the next dose and contact the prescriber is the initial action to prevent further toxicity and adjust the medication regimen. Choice A is incorrect because the level is above the therapeutic range. Choice C is unnecessary unless the patient is experiencing severe symptoms. Choice D is not the initial intervention; holding the next dose is more immediate.

Correct Answer: A

Rationale: The correct answer is A because seeing oneself as capable of achieving ideals and meeting demands indicates a positive self-perception and mental strength, aligning with the goal of demonstrating mentally healthy behavior. Choice B is incorrect as it describes impulsive behavior, which is not indicative of mental health. Choice C suggests aggressive and selfish behavior, which goes against mental health principles. Choice D, seeking help when needed, is important but does not directly demonstrate the achievement of mentally healthy behavior like choice A does.

Correct Answer: D

Rationale: The correct answer is D because the client's statement about the partner being 'sorry' for their breakup indicates potential harm or danger. This statement may suggest thoughts of retaliation or harm towards the partner, raising concerns for safety and potential violence. It should be the nurse's priority to assess the client's risk of harm to themselves or others. Explanation of why the other choices are incorrect: A: The client being silent during some interviews may indicate anxiety or distress, but it does not necessarily pose an immediate safety concern. B: A history of preeclampsia with a past pregnancy is important for medical history but does not indicate an immediate risk to the client's safety. C: The family bringing in magazines is not a critical detail that raises concerns about the client's safety or well-being.

Correct Answer: A

Rationale: The correct answer is A: Problem stimulating usual problem solving. In crisis intervention, the first phase is when the individual encounters a problem that triggers their usual problem-solving skills. This initial phase involves recognizing the crisis and attempting to assess and address the problem. This sets the stage for further crisis intervention strategies. Choices B, C, and D are incorrect: B: Trial and error attempts to alleviate problem - This typically occurs after the crisis has been recognized and initial problem-solving attempts have been made. C: Automatic relief behaviors take over - This is more likely to be a coping mechanism employed after the crisis has escalated and the individual is seeking immediate relief. D: Serious personality disorganization - This usually occurs in the later stages of a crisis when the individual's ability to cope is severely compromised.

Correct Answer: B

Rationale: The correct answer is B because a lithium level of 1.7 mEq/L is above the therapeutic range (0.6-1.2 mEq/L), indicating potential toxicity. Instructing the patient to hold the next dose and contact the prescriber is the initial action to prevent further toxicity and adjust the medication regimen. Choice A is incorrect because the level is above the therapeutic range. Choice C is unnecessary unless the patient is experiencing severe symptoms. Choice D is not the initial intervention; holding the next dose is more immediate.