Difficulty: Medium
Average Score: 72%
Simulated
A nurse is caring for a client who is taking lithium and reports experiencing lethargy, muscle weakness, and blurred vision. Which of the following responses should the nurse make?
Correct answer
D
Rationale
The correct answer is D: "You will need to have your blood drawn." This response is correct because lithium is a medication that requires monitoring of blood levels due to its narrow therapeutic range. Lethargy, muscle weakness, and blurred vision are symptoms of lithium toxicity, which can occur if the blood levels of lithium become too high. By having the client's blood drawn, the nurse can assess the lithium levels and make necessary adjustments to the dosage to prevent further toxicity.
Incorrect Responses:
A: "These symptoms will improve over time." - This is incorrect because the symptoms described are indicative of lithium toxicity, which requires immediate attention.
B: "Continue the medication as prescribed." - This is incorrect because if the client is experiencing symptoms of toxicity, continuing the medication without monitoring could lead to further complications.
C: "You should decrease your intake of sodium." - This is incorrect as it does not address the issue of lithium toxicity. Sodium intake is not directly related to lithium toxicity.
Incorrect Responses:
A: "These symptoms will improve over time." - This is incorrect because the symptoms described are indicative of lithium toxicity, which requires immediate attention.
B: "Continue the medication as prescribed." - This is incorrect because if the client is experiencing symptoms of toxicity, continuing the medication without monitoring could lead to further complications.
C: "You should decrease your intake of sodium." - This is incorrect as it does not address the issue of lithium toxicity. Sodium intake is not directly related to lithium toxicity.