A client taking lithium develops vomiting, a coarse tremor, ataxia, and confusion. Place the nurse's actions in priority order.
Ordered Response
Choose your responses, then check the answer.
Explanation
The nurse first assesses and stabilizes the client, then prevents additional lithium exposure. Safety precautions reduce injury from ataxia, confusion, or seizures. Urgent escalation and laboratory evaluation determine severity and treatment. Ongoing reassessment, documentation, and handoff follow.
Correct sequence Assess and stabilize → hold lithium → protect from injury → escalate and obtain studies → reassess and communicate.
Why this is correct Vomiting, coarse tremor, ataxia, and confusion are not expected mild effects. Dehydration, sodium loss, reduced renal clearance, diuretics, ACE inhibitors, and NSAIDs can raise lithium exposure. The therapeutic and toxic ranges are close, and symptoms may be serious even before a level returns. The due dose should not be given while toxicity is suspected.
NCLEX decision rule With suspected medication toxicity, assess immediate stability, stop further exposure when safe within nursing authority, protect the client, escalate, and trend objective response data.
Reference
1DailyMed: lithium carbonateNeurologic toxicity, dehydration and sodium risk, renal interactions, and discontinuation or dose reduction
Suspected lithium toxicityThe client recently had diarrhea and started an NSAID. The next lithium dose is due now.
Lithium Toxicity — Excess lithium effect that can cause GI and neurologic symptoms.
Ataxia — Impaired coordination that can increase fall risk.
Serum Lithium Level — A blood concentration used to monitor lithium therapy and toxicity.