# A patient with bipolar I disorder on chronic lithium therapy presents to the ED after several days of vomiting and diarrhea from a viral illness. Serum lithium is 1.7 mEq/L. Which clinical findings and nursing actions are appropriate? Select all that apply.

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=372860&lang=en  
> language: en  
> subject: Psychosocial Integrity  
> category: PSI

## Question

A patient with bipolar I disorder on chronic lithium therapy presents to the ED after several days of vomiting and diarrhea from a viral illness. Serum lithium is 1.7 mEq/L. Which clinical findings and nursing actions are appropriate? Select all that apply.

1

Hold the next lithium dose and notify the provider; therapeutic range is 0.6 to 1.2 mEq/L and 1.7 represents mild-to-moderate toxicity.

2

Anticipate hemodialysis if serum lithium reaches or exceeds 2.5 mEq/L or if neurologic findings progress despite supportive care.

3

Increase oral fluid intake (and IV isotonic fluids if dehydrated) to support renal lithium excretion.

4

Assess for coarse tremor, ataxia, slurred speech, confusion, and muscle twitching as classic toxicity findings.

5

Recommend a low-sodium diet because reducing dietary sodium intake will increase the kidneys' ability to excrete lithium.

## Explanation

Lithium has a narrow therapeutic window (0.6-1.2). Volume depletion from GI losses concentrates lithium and triggers toxicity. Priorities: hold the dose, notify provider, recognize coarse tremor/ataxia/slurred speech as toxicity (not therapeutic effect), rehydrate, and prepare for dialysis at severe levels (≥2.5) or progressive neuro symptoms. Choice 5 is wrong — LOW sodium causes the kidneys to reabsorb MORE lithium, raising serum levels; patients should maintain consistent sodium and water intake.

## In-depth explanation

Sodium balance and lithium are linked: anything that drops sodium (low-salt diet, thiazides, vomiting, sweating) raises lithium. The single most important teaching point for chronic lithium patients is "do not change your salt or water intake suddenly" — and call the provider for any GI illness, fever, or new diuretic.

## Clinical scenario

**Bipolar I patient on chronic lithium** presents after several days of **vomiting and diarrhea** from a viral illness. Serum lithium **1.7 mEq/L** (therapeutic 0.6-1.2). The patient now reports coarse tremor and unsteady gait.

## Key concepts

- **Lithium toxicity** — Mild 1.5-2.0, moderate 2.0-2.5, severe >2.5; presents with tremor, GI symptoms, ataxia, dysarthria, confusion, seizures.
- **Coarse tremor** — Large-amplitude tremor distinct from the fine tremor of therapeutic lithium use; signals toxicity.
- **Hemodialysis indication** — Severe toxicity (>2.5-4.0 mEq/L), progressive neurologic findings, or renal failure preventing excretion.

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