# Review the client's changing hydration, renal, neurologic, and lithium data and determine the priority response.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=547006&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## Question

Review the client's changing hydration, renal, neurologic, and lithium data and determine the priority response.

| Time | Data |
| --- | --- |
| Day 1 | Lithium 0.9 mEq/L; creatinine 1.0 mg/dL; sodium 139 mEq/L; mild fine hand tremor; eating and drinking normally. |
| Day 3 | Repeated diarrhea and poor intake; took ibuprofen; sodium 133 mEq/L; creatinine 1.4 mg/dL; new coarse tremor and nausea. |
| Day 4 | Persistent vomiting, confusion, unsteady gait; lithium 1.9 mEq/L; creatinine 1.8 mg/dL; sodium 131 mEq/L. |

Q1. How should the nurse interpret the overall pattern?

Stable therapeutic response
Expected isolated fine tremor
Primary anxiety without medication involvement
Progressive lithium toxicity from volume depletion and reduced renal clearance

Q2. What is the priority response?

Hold lithium, obtain urgent medical evaluation, and begin indicated isotonic fluid and monitoring support
Give the next lithium dose with food
Administer more ibuprofen for discomfort
Restrict sodium and fluid

Q3. Which ongoing assessment set is most important?

Skin testing and visual acuity only
Daily weight without laboratory follow-up
Neurologic status, renal function, electrolytes, serial lithium levels, and cardiac status
Bowel sounds only after every meal

## Explanation

Volume and sodium depletion increase renal lithium reabsorption, and worsening kidney function reduces lithium clearance. NSAIDs can further increase lithium exposure. The progression from gastrointestinal illness to coarse tremor, vomiting, ataxia, and confusion with rising lithium and creatinine indicates toxicity. The nurse should hold lithium, notify the prescriber urgently, begin indicated isotonic fluid support, obtain serial lithium, renal, electrolyte, neurologic, and cardiac assessments, and escalate for toxicology or dialysis consultation when severity or trajectory warrants. Giving the next dose or treating tremor alone is unsafe.

## In-depth explanation

Correct Answer
The client has worsening lithium toxicity promoted by dehydration, sodium depletion, NSAID exposure, and renal impairment.

Why It Fits
Neurologic and gastrointestinal symptoms intensify while lithium and creatinine rise after volume loss and ibuprofen use.

Clinical Picture
The serum value supports the diagnosis, but treatment urgency also depends on symptoms, renal function, chronicity, and trajectory.

Memory Link
Lithium follows sodium and kidney clearance; dry kidneys retain it.

NCLEX Rule
Hold lithium and urgently correct volume and electrolyte disturbances while monitoring neurologic, renal, cardiac, and serial drug data; severe cases need expert dialysis evaluation.

Why the Alternatives Fail
Continuing lithium, adding an NSAID, or focusing only on the tremor allows systemic toxicity to progress.

Sources
1DailyMed Lithium Carbonate Prescribing Information
2NCSBN 2026 NCLEX-RN Test Plan

## Clinical scenario

Medical unit
An adult takes lithium carbonate for bipolar disorder. The client develops gastroenteritis, continues the usual lithium dose, and takes over-the-counter ibuprofen for fever. The nurse reviews serial findings.

## Key concepts

- **Lithium toxicity** — A potentially serious toxic state with gastrointestinal, neurologic, renal, and cardiac manifestations from excessive lithium exposure.
- **Coarse tremor** — A prominent, irregular tremor that is more concerning for lithium toxicity than a mild fine tremor.
- **Renal clearance** — Removal of a substance by the kidneys; declining clearance increases lithium accumulation.

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