Psych Exam 2 ATI Qs

A nurse is caring for a client who has depression. The client states, "I am too tired and depressed to attend group therapy today." Which of the following responses should the nurse make? A. "Attending group therapy, even if you're tired, is an important part of your treatment." B. "It's okay if you're too tired to attend group therapy today, but you will have to go tomorrow." C. "It is normal to be tired when you're feeling depressed. The others in group therapy feel the same way." D. "I agree with your decision to wait to participate in group therapy until you begin to feel better."

A. "Attending group therapy, even if you're tired, is an important part of your treatment."

A nurse is caring for a client with obsessive-compulsive disorder (OCD) who has been taking fluoxetine for 3 months. The client states, "This medication isn't working. I want to stop taking it." Which of the following responses should the nurse make? A. "It is best to discontinue the medication slowly over 1 or 2 months." B. "If the medication hasn't helped you in 3 months, it's not going to." C. "You will likely gain weight if you stop taking the medication." D. "This medication is the only treatment available for your condition."

A. "It is best to discontinue the medication slowly over 1 or 2 months."

A nurse is teaching a client who has seasonal affective disorder (SAD) about the use of light therapy. Which of the following statements should the nurse make? A. "Light therapy suppresses the natural nighttime release of melatonin." B. "You should plan your light therapy session before going to bed." C. "You should begin with 2-minute light therapy sessions and gradually progress to 10-minute sessions." D. "Light therapy is less effective at treating SAD than antidepressant medications."

A. "Light therapy suppresses the natural nighttime release of melatonin."

A nurse is caring for a client with premenstrual disorder (PMD) who has a prescription for fluoxetine. The client asks the nurse, "When should I notice the benefits of this medication?" Which of the following responses should the nurse make? A. "You should expect decreased manifestations within a few days." B. "Manifestations decrease after about 2 months." C. "You should expect decreased manifestations immediately." D. "Manifestations will decrease after several weeks."

A. "You should expect decreased manifestations within a few days." The nurse should inform the client that fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used to treat PMD. Unlike using fluoxetine to treat depression, using fluoxetine to treat PMD will improve manifestations more quickly.

A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) to treat major depression. Following the procedure, which of the following actions should the nurse take? A. Administer oxygen B. Administer an anticonvulsant C. Administer an opioid antagonist D. Administer IV fluids

A. Administer oxygen In preparation for ECT, the anesthesiologist administers succinylcholine, which paralyzes respiratory muscles. Clients require oxygen administration until their respiratory status is stable.

A nurse is caring for a client who has bipolar disorder and is experiencing hypomania. During a conversation with other clients, she becomes agitated and begins speaking in a loud, angry voice. Which of the following actions should the nurse take? A. Ask the client to take a walk B. Reprimand the client for her rude behavior C. Point out inappropriate behaviors to the client D. Administer trazodone to the client

A. Ask the client to take a walk The client's increasing agitation demonstrates a potential for violent behavior. To maintain a safe environment, the nurse should remove the client from the situation and disperse the anger by walking and talking with her.

A nurse on an inpatient mental health unit is attending an interdisciplinary treatment team meeting for a client who has bipolar disorder with rapid cycling. The client is being prepared for discharge following his fourth admission in the last year. Which of the following referrals should the nurse make for the client first? A. Assertive community treatment B. Support group C. Private counseling D. Vocational rehabilitation services

A. Assertive community treatment

A nurse is planning discharge teaching for a client who has major depressive disorder and a new prescription for phenelzine. Which of the following foods should the nurse include in the plan as safe for the client to consume while taking phenelzine? A. Broiled beef steak B. Macaroni and cheese C. Pepperoni pizza D. Smoked salmon

A. Broiled beef steak Phenelzine, an MAOI, is an antidepressant. This medication interacts with a variety of foods to produce a hypertensive crisis. Beef steak and other meats that are fresh do not interact with phenelzine and are safe to consume.

A nurse is assessing a client who takes phenelzine for the treatment of depression. Which of the following findings is the priority for the nurse to report to the provider? A. Elevated blood pressure B. Weight gain C. Muscle twitching D. 2+ peripheral edema

A. Elevated blood pressure The greatest risk to this client is an elevated blood pressure, which increases the risk of a hypertensive crisis that can result from taking an MAOI like phenelzine. The nurse should apply the safety and risk reduction priority-setting framework when assessing this client, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the risk posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Incorrect Answers: B. Weight gain C. Muscle twitching D. Peripheral edema are common adverse effects of an MAOI like phenelzine

A nurse in an acute care mental health facility observes a client who has bipolar disorder begin to shout and use offensive language toward a visitor. Which of the following actions should the nurse take? A. Give the client 2 options for ending the situation B. Move quickly to stand directly in front of the client before speaking C. Direct other clients to move toward the client as a show of force D. Tell the client that the conversation will be ended if the shouting continues

A. Give the client 2 options for ending the situation

A nurse is caring for a client who has bipolar disorder and a new prescription for valproic acid. Which of the following actions should the nurse take? A. Monitor the client's liver function B. Avoid giving the medication with food or milk C. Counsel the client regarding medication dependency D. Limit intake of foods containing tyramine

A. Monitor the client's liver function Valproic acid can cause severe hepatotoxicity and liver failure. The nurse should monitor the client's liver function at baseline and periodically thereafter. The nurse should also teach the client about the manifestations of liver failure.

A nurse is planning a staff education session about the administration of antidepressant medications to older adult clients. Which of the following pieces of information should the nurse include in the teaching? A. Older adult clients require a lower initial dose of antidepressant medication than adult clients. B. Older adult clients should not receive antidepressant medication. C. Older adult clients achieve the therapeutic effects of antidepressant medications more quickly than adult clients. D. Older adult clients have a decreased risk of experiencing adverse effects from antidepressant medication.

A. Older adult clients require a lower initial dose of antidepressant medication than adult clients.

A nurse is conducting a risk assessment for clients who are prescribed medications that can cause orthostatic hypotension. Which of the following medications requires a follow-up by the nurse? A. Phenelzine B. Escitalopram oxalate C. Galantamine D. Naltrexone

A. Phenelzine Phenelzine is a monoamine oxidase inhibitor that is prescribed for depression and other mental health disorders. An adverse effect of phenelzine is orthostatic hypotension. The nurse should inform the client who is taking phenelzine that dizziness and lightheadedness are indications of hypotension. The nurse should also instruct the client to rise slowly from a lying or sitting position to minimize a drop in blood pressure. SSRIs d/n cause orthostatic hypotension

A nurse is assessing a client prior to administering lithium. The client began taking lithium 1 week ago for the treatment of mania. For which of the following findings should the nurse withhold the dose? A. Report of nausea with frequent episodes of emesis B. Weight gain of 1.8 kg (4 lb) since the start of treatment C. Fine hand tremors in both hands D. Serum lithium level of 1.1 mEq/L

A. Report of nausea with frequent episodes of emesis Gastrointestinal upset with nausea and frequent emesis is an early indication of lithium toxicity; therefore, the nurse should withhold the prescribed dose and obtain a serum lithium level. The nurse should assess the client for indications of dehydration, which further increases the risk of lithium toxicity.

A nurse in an emergency department is assessing a client who has bipolar disorder and is in a manic state. Which of the following findings is the highest priority? A. The client reports sleeping 2 to 3 hours per night. B. The client speaks to the nurse in a demanding tone. C. The client reports not attending group therapy. D. The client reports not taking medication for the past 2 weeks.

A. The client reports sleeping 2 to 3 hours per night. The greatest risk to this client is an injury from exhaustion due to lack of sleep; therefore, the priority finding is the client's report of decreasing sleep time.

A nurse is providing discharge teaching to a client who has been hospitalized for major depressive disorder and has a prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching? A. "I will take amitriptyline in the morning because I'll likely have trouble falling asleep if I take it in the evening." B. "I will move slowly when I stand up because amitriptyline can cause my blood pressure to decrease." C. "I can drink a glass of beer or wine with my evening meal because amitriptyline doesn't interact with alcohol." D. "I will avoid foods that are high in fiber because amitriptyline can cause diarrhea."

B. "I will move slowly when I stand up because amitriptyline can cause my blood pressure to decrease." Amitriptyline can cause orthostatic hypotension. The nurse should instruct the client to take precautions to prevent an injury due to a fall while taking amitriptyline.

A nurse is teaching a client who has major depressive disorder and is scheduled to begin electroconvulsive therapy (ECT). Which of the following pieces of information should the nurse include? A. "If you're taking a benzodiazepine medication, you should take it before the procedure." B. "You can expect to wake up about 15 minutes after the procedure." C. "After the first procedure, you should expect to have ECT sessions monthly for a year." D. "ECT is the primary treatment for most clients who have depression."

B. "You can expect to wake up about 15 minutes after the procedure." ECT is typically prescribed 2 or 3 times a week for approximately 6 to 12 treatments total Medication is the primary treatment for most clients who have depression. ECT might be the first-line treatment in specific situations such as delusional depression or if a client cannot take medications due to other medical problems.

A nurse is caring for a client who has depression. The nurse observes that the client has not come to breakfast and is still in bed. The client states, "I'm not worth your time. Leave me alone and go help someone else." Which of the following responses should the nurse make? A. "Many people feel this way when they first start treatment." B. "You seem to be saying that you feel unworthy of help." C. "You'll feel better once you get up and have some breakfast." D. "I disagree. You are certainly worth my time."

B. "You seem to be saying that you feel unworthy of help."

A nurse is teaching an assistive personnel (AP) about dietary restrictions for a client who is taking phenelzine to treat depression. The AP's selection of which of the following foods for the client's lunch indicates an understanding of the teaching? A. Bologna on wheat bread B. Chicken salad C. Cheddar cheese and crackers D. Pizza with pepperoni

B. Chicken salad Phenelzine is an MAOI. Clients taking MAOIs must avoid foods that contain tyramine due to the potential for a dangerous food-drug interaction. Foods high in tyramine include those that are processed and aged, such as luncheon meats and cheeses. This menu selection does not contain food high in tyramine and indicates an understanding of the teaching.

A nurse is caring for a client with bipolar disorder who is experiencing mania. Which of the following actions is the nurse's priority? A. Offer the client finger foods every 2 hours B. Determine if the client is a danger to herself C. Monitor the client's vital signs every 2 hours D. Move the client to a quiet area

B. Determine if the client is a danger to herself

A nurse is updating the plan of care for a client who has major depression and a new prescription for amitriptyline. The nurse should plan to monitor the client for which of the following adverse effects? A. Hypertension B. Drowsiness C. Panic attacks D. Diarrhea

B. Drowsiness Drowsiness is an expected side effect of amitriptyline and other tricyclic antidepressants. Sedation is most likely to be present during the first weeks of treatment with amitriptyline and can increase the risk of falls. other sfx - hypoBP - EKG changes - SI - antichol sfx (constip not diarr)

A nurse is planning care for a client who has bipolar disorder and has acute mania. Which of the following interventions should the nurse include in the plan? A. Provide the client with a low-calorie, low-fat diet B. Encourage the client to have frequent rest periods C. Escort the client to daily group therapy D. Limit the client's intake of caffeinated beverages to 12 oz per day

B. Encourage the client to have frequent rest periods The nurse should encourage the client to have frequent rest periods throughout the day to decrease the client's risk of exhaustion. Because of the constant activity associated with acute mania, the nurse should encourage brief rest periods each hour. Also, the pt should have high-cal/ high-prot, they need decreased stimulation.. so no group activities and NO Caffeine

A nurse is reviewing the plan of care for a client who has bipolar disorder. Which of the following is an effect of using cognitive behavioral therapy (CBT) for a client who has bipolar disorder? A. Prevents the need for mood-stabilizing medications B. Helps the client deal with distorted thought processes C. Aids communication among family members D. Replaces the need for lifestyle interventions

B. Helps the client deal with distorted thought processes

A nurse is planning care for a client who has a seizure disorder and a new prescription for valproic acid. Which of the following laboratory values should the nurse plan to monitor? (Select all that apply.) A. BUN B. PTT C. Aspartate aminotransferase (AST) D. Urinalysis E. Alanine aminotransferase (ALT)

B. PTT C. Aspartate aminotransferase (AST) E. Alanine aminotransferase (ALT)

A nurse is teaching a client who has depression and is scheduled for transcranial magnetic stimulation (TMS). The nurse should inform the client that TMS can cause which of the following adverse effects? A. Retrograde amnesia B. Seizures C. Confusion D. Suicidal ideation

B. Seizures Although uncommon, seizures are a potential adverse effect of TMS. Incorrect: A. Retrograde amnesia is a potential adverse effect of electroconvulsive therapy rather than TMS. C. Confusion is a potential adverse effect of electroconvulsive therapy rather than TMS. D. Suicidal ideation is a manifestation of depression. TMS is prescribed as a treatment for depression and is intended to decrease suicidal ideation and other manifestations of depression such as guilt, hopelessness, sadness, and excessive crying.

A nurse is reviewing the medical record of a client who has a new prescription for tranylcypromine. The client still has a current prescription for sertraline. The nurse should notify the provider because taking these medications concurrently increases the risk of which of the following adverse effects? A. Increased intracranial pressure B. Serotonin syndrome C. Acute kidney injury D. Hypertensive crisis

B. Serotonin syndrome Serotonin syndrome is a toxic effect that can occur from taking an MAOI such as tranylcypromine and an SSRI such as sertraline simultaneously. Manifestations include delirium, abdominal pain, muscle spasms, and irritability, and the condition can worsen to cause cardiovascular shock and death. The nurse should notify the provider immediately of this potential interaction.

A nurse is discussing the benefits of group therapy with a client who has bipolar disorder. Which of the following is an advantage of this form of treatment? A. Decreased pressure from others to engage in unacceptable behaviors B. The chance to learn from the experiences of other individuals C. An outlet for increased energy during episodes of mania D. The opportunity to have increased participation in therapy

B. The chance to learn from the experiences of other individuals

A nurse in a clinic is assessing a client who states that she needs help with depression. Which of the following questions is the nurse's priority? A. "Is there anything in particular that makes you feel angry?" B. "Have you had difficulty falling asleep or staying asleep?" C. "Have you thought about harming yourself in any way?" D. "Do you have someone you can talk to at home?" Check Answer

C. "Have you thought about harming yourself in any way?"

A nurse is providing discharge teaching about lithium toxicity to a client who has a new prescription for lithium. Which of the following statements by the client indicates an understanding of the teaching? A. "I should take naproxen if I have a headache because aspirin can cause lithium toxicity." B. "I can develop lithium toxicity if I eat foods with lots of sodium." C. "I can develop lithium toxicity if I experience vomiting or diarrhea." D. "I might need to take a daily diuretic along with my lithium to prevent lithium toxicity."

C. "I can develop lithium toxicity if I experience vomiting or diarrhea."

A nurse is caring for a client who has major depressive disorder and recently started taking an antidepressant. The nurse should identify which of the following client statements as the priority? A. "I hate being so helpless. I can't even manage my own finances anymore." B. "At group therapy today, I wanted to leave. I didn't feel like being with other people." C. "I have it all figured out. Everything is going to be okay now." D. "I don't feel like showering. I'd rather just stay in bed today."

C. "I have it all figured out. Everything is going to be okay now."

A nurse is teaching a client who has a prescription for a tricyclic antidepressant. Which of the following instructions should the nurse include in the teaching? A. "Take this medication within 1 hour of waking each morning." B. "Limit alcohol to 2 drinks per week while taking this medication." C. "It can take 6 weeks to achieve the full therapeutic effect of this medication." D. "Stop taking the medication if you experience dizziness."

C. "It can take 6 weeks to achieve the full therapeutic effect of this medication."

A nurse in a mental health clinic is caring for a client who has bipolar disorder and states, "I no longer take my medication because I like the feeling of being manic." Which of the following responses by the nurse is an example of therapeutic communication? A. "You might feel good now, but what about when you get depressed?" B. "Why do you think you like feeling manic?" C. "You feel better when you don't take your medication?" D. "What do you think your provider will say about missing your medication?"

C. "You feel better when you don't take your medication?"

A nurse is caring for a client who has depression and started taking paroxetine 1 week ago. The client states to the nurse, "My family would be better off without me." Which of the following responses should the nurse make? A. "Why do you feel your family would be better off without you?" B. "Many people feel this way when they are depressed." C. "You sound upset. Are you thinking of hurting yourself?" D. "Your medication hasn't started working yet. Soon, you'll be feeling differently."

C. "You sound upset. Are you thinking of hurting yourself?"

A nurse is planning to administer a dose of lithium carbonate to a client who has bipolar disorder. The laboratory report indicates the client's current lithium level is 1.0 mEq/L. Which of the following actions should the nurse take? A. Contact the provider for a dosage increase B. Request a repeat of the lithium level C. Administer the medication D. Prepare the client for gastric lavage

C. Administer the medication

A nurse is planning a menu for a client who has bipolar disorder and is experiencing an acute manic episode. Which of the following meals should the nurse provide for this client? A. Spaghetti with meatballs, a salad, and apple pie B. Beef and vegetable stew, rice, and vanilla pudding C. Chicken nuggets, crackers with cheese sticks, and a cookie D. Broiled fish fillets, stewed tomatoes, and ice cream

C. Chicken nuggets, crackers with cheese sticks, and a cookie A client who is in the manic phase of bipolar disorder should receive high-calorie finger foods that can be carried and are relatively easy to manipulate. This meal is a good choice for a client who is hyperactive, has a short attention span, and might not sit down to eat.

A nurse is caring for a client who has bipolar disorder. Which of the following manifestations is the priority finding for the nurse to identify? A. Inability to concentrate B. Poor hygiene C. Hyperactivity D. Pressured speech

C. Hyperactivity The greatest risk to this client is an injury from hyperactivity; therefore, the priority finding for the nurse to identify is hyperactivity. The nurse should intervene to redirect the client from unsafe activities. Constant activity can lead to exhaustion and even death.

A nurse in a mental health facility is meeting with a client who has a diagnosis of major depression. During the conversation, the client stops speaking, and the nurse sits silently next to the client for several minutes. The nurse should identify that the therapeutic communication technique of silence is used for which of the following purposes? A. To show approval of the client's desire to not talk B. To give the client time to evaluate the nurse C. To encourage the client to express feelings or concerns D. To prevent the nurse from making a nontherapeutic response

C. To encourage the client to express feelings or concerns Silence during therapeutic communication has many functions, including providing the client with time to formulate thoughts and express feelings or concerns. During the silence, the client can also consider alternatives and think about what has been said.

A nurse is reviewing the medications of a client who has bipolar disorder and a new prescription for lithium. Which of the following medications may be administered safely while the client is taking lithium? A. Ibuprofen B. Haloperidol C. Valproic acid D. Hydrochlorothiazide

C. Valproic acid not ibuprofen bc kidneys, not haloperidol bc EPS, tardives sfx, and not diuretics bc sodium loss

A nurse is providing dietary teaching to a client who has a new prescription for a monoamine oxidase inhibitor (MAOI). Which of the following food selections by the client indicates an understanding of the teaching? A. Cheddar cheese B. Avocados C. Pepperoni D. Yogurt

D. Yogurt Yogurt does not contain high amounts of tyramine and is allowed for clients who are taking an MAOI medication.

A nurse at an acute mental health facility is caring for a client who has acute mania due to bipolar disorder. At 0300, the client runs to the nurse's station and demands to see the provider immediately. Which of the following responses should the nurse offer? A. "Your request is unreasonable. We cannot call your provider at 3:00 in the morning." B. "If you can calm down for 5 min, then I will call your provider for you." C. "Calm down, go back to your room, and come back in 15 min so we can talk about how you're feeling." D. "You must be very upset about something to want to see your provider in the middle of the night."

D. "You must be very upset about something to want to see your provider in the middle of the night." The nurse should respond to the client's concern with empathy, which shows understanding of the client's feelings and offers an opportunity for the client to clarify the situation.

A nurse is providing teaching to a client who is scheduled to start taking valproic acid. Which of the following instructions should the nurse include? A. "You should expect the provider to decrease your dosage of valproic acid gradually." B. "You should take aspirin for pain while taking valproic acid." C. "You should undergo thyroid function tests every 6 months while taking valproic acid." D. "You should have your liver function levels monitored regularly while taking valproic acid."

D. "You should have your liver function levels monitored regularly while taking valproic acid." The nurse should inform the client of the need to monitor liver function levels due to the risk of hepatotoxicity while taking valproic acid. Current recommendations advise obtaining baseline levels and repeating tests every 2 months during the first 6 months of therapy.

A nurse is assessing a client who is taking lithium to treat bipolar disorder and has a lithium level of 2.2 mEq/L. Which of the following findings should the nurse expect? A. Muscle weakness B. Oliguria C. Vomiting D. Blurry vision

D. Blurry vision Manifestations of lithium toxicity with levels between 2 and 2.5 mEq/L include blurry vision, ataxia, clonic twitching, severe hypotension, and polyuria. /// A. Muscle weakness and fine hand tremors are early manifestations of lithium toxicity. These manifestations are common with lithium levels between 1.0 and 1.5 mEq/L. B. Manifestations of lithium toxicity with levels above 2.5 mEq/L include seizures and oliguria. For levels above 3.5 mg/dL, delirium, cardiovascular collapse, coma, and death can occur. C. Nausea, vomiting, diarrhea, and lethargy are early manifestations of lithium toxicity. These manifestations are common with lithium levels between 1.0 and 1.5 mEq/L.

A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing acute mania. Which of the following client goals should the nurse identify as the priority? A. Practicing problem-solving skills B. Understanding the medication regimen C. Identifying indications of relapse D. Maintaining adequate hydration

D. Maintaining adequate hydration

A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan? A. Discourage the client from taking naps during the day. B. Allow the client to choose which items of clothing to wear each day. C. Encourage the client to participate in group therapy. D. Provide the client frequently with high-calorie finger-foods

D. Provide the client frequently with high-calorie finger-foods

A nurse is assessing a school-aged child who has ADHD and has been taking desipramine. Which of the following adverse effects should the nurse expect the child's parent to report? A. Hyperactivity B. Depression C. Diarrhea D. Sedation

D. Sedation The nurse should recognize that tricyclic antidepressants can cause sedation, along with other anticholinergic effects. Therefore, the nurse should expect the parent to report that the child has been sedated.

A nurse is providing discharge teaching to the guardians of an adolescent who has bipolar disorder. Which of the following manifestations should the nurse identify as an indication of acute mania? (Select all that apply.) A. Completes school projects B. Naps during the daytime C. Eats large amounts D. Spends excessive amounts of money E. Speaks crassly using a loud voice

D. Spends excessive amounts of money E. Speaks crassly using a loud voice The nurse should identify that a client who has acute mania is impulsive and at risk for spending excessive amounts of money despite financial status. Additionally, a client who has acute mania has rapid speech and quick thoughts. Other alterations in speech include speech that is vulgar or sexually explicit

A nurse is assessing the lethality of a client's plan for committing suicide. Which of the following plans should the nurse identify as a soft method of suicide? A. Jumping off a bridge B. Inhaling carbon monoxide C. Hanging with a rope D. Swallowing antidepressant pills

D. Swallowing antidepressant pills The nurse should assess the lethality of a client's suicide plan and identify the method as hard or soft. Ingesting antidepressants or other pills is considered a soft method due to the lower risk of resulting in death. Hard methods include jumping from a high place, carbon monoxide inhalation, hanging, and using a gun.

A nurse is completing an admission assessment for an adolescent client who has depression. The nurse should identify which of the following findings as the priority? A. The client is confrontational with his parents. B. The client is getting Ds in his classes because he frequently skips school. C. The client states he smokes half a pack of cigarettes per day. D. The client gave his favorite possessions to friends.

D. The client gave his favorite possessions to friends.

A nurse is reviewing the health history of a young adult client who has a depressive disorder. Which of the following factors increases the client's risk of depression? A. The client is an only child. B. The client lives in an urban setting. C. The client is married. D. The client is female.

D. The client is female. The nurse should identify female gender as a primary risk factor for depression. The incidence of depressive disorders is greater in women than in men by a ratio of almost 2 to 1.

A nurse is caring for a client who is taking a tricyclic antidepressant. Which of the following adverse effects should the nurse report to the client's provider immediately? A. Dry mouth B. Constipation C. Drowsiness D. Urinary retention

D. Urinary retention Urinary retention can lead to bladder infection and, ultimately, a loss of bladder tone. The nurse should apply the safety and risk reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client.

A nurse is evaluating teaching for a client who has bipolar disorder and a new prescription for lithium. Which of the following statements by the client indicates an understanding of the teaching? A. "I should take lithium on an empty stomach." B. "I can take ibuprofen for headaches while taking lithium." C. "I need to limit my salt intake while taking lithium." D. "I am likely to gain weight while taking lithium."

D. "I am likely to gain weight while taking lithium." The nurse should instruct the client to eat a low-calorie diet while taking lithium because this medication can cause weight gain. take lithium w food or milk to prev GI upset