# A client taking lithium for bipolar disorder has had vomiting and severe diarrhea for 2 days and is now tremulous, drowsy, and unsteady. The morning lithium dose is due. Complete the priority plan.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=394733&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

A client taking lithium for bipolar disorder has had vomiting and severe diarrhea for 2 days and is now tremulous, drowsy, and unsteady. The morning lithium dose is due. Complete the priority plan.

The nurse should ::선택::hold lithium and notify the provider or emergency response pathwaygive the scheduled lithium before laboratory testingdouble the dose after one glass of waterwait for the next routine clinic visit, anticipate ::선택::a fasting lipid panel onlya serum lithium concentration, electrolytes, BUN, creatinine, and ECGa peak vancomycin concentrationa stool occult blood test only, and ::선택::stop neurologic assessment after the dose is heldtreat diarrhea only and discharge immediatelycontinue neurologic and cardiac monitoring and give prescribed isotonic fluid replacementrestrict all fluid despite volume depletion.

## Explanation

Prolonged vomiting and diarrhea can cause sodium and volume depletion, reduce lithium clearance, and precipitate toxicity. Tremor, drowsiness, and unsteady gait are neurologic warning signs. Hold lithium and notify the provider or rapid-response pathway; do not wait for a serum concentration before acting on toxicity cues. Anticipate a timed serum lithium concentration, electrolytes, blood urea nitrogen, creatinine, and an ECG, together with repeated neurologic and cardiac assessment. Prescribed isotonic fluid replacement is commonly required when volume depletion is present, while the team evaluates severity and the need for poison-control, toxicology, or nephrology consultation.

## In-depth explanation

Correct Answer
Hold lithium, escalate urgently, obtain a lithium concentration with renal and electrolyte studies, and begin monitored supportive care with prescribed isotonic fluid replacement when appropriate.

Why It Fits
Diarrhea and vomiting cause sodium and volume loss. The kidneys then retain more lithium, and neurologic findings such as tremor, drowsiness, and ataxia signal possible toxicity even before a laboratory result returns.

Clinical Picture
Lithium travels with body water and sodium balance. When fluid and sodium are lost, the lithium concentration can rise and the brain becomes an early warning system.

Memory Link
Lithium plus GI loss plus neurologic change: hold, hydrate as ordered, check level and kidneys, monitor.

NCLEX Rule
Act on clinical toxicity cues rather than administering the scheduled dose and waiting for the next visit. A lithium concentration supports the diagnosis but does not replace immediate safety actions.

Why the Alternatives Fail
Giving another dose can worsen toxicity. An antidiarrheal alone does not correct lithium accumulation or dehydration. A normal past lithium level does not rule out new toxicity after acute fluid loss.

Source
1FDA Prescribing Information: Lithium and Lithium Carbonate

## Clinical scenario

The client has reduced oral intake and signs of volume depletion. No additional lithium has been given today, and urgent laboratory testing and monitored treatment are available.

## Key concepts

- **Lithium** — A mood stabilizer with a narrow therapeutic range requiring monitoring for toxicity.
- **Bipolar Disorder** — A mood disorder characterized by episodes of mania or hypomania and often depression.
- **Serum Drug Level** — A blood measurement used to evaluate whether a medication concentration is therapeutic or toxic.

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