# Stage 1 — Recognize cues. The nurse reviews the admission assessment. Highlight the findings that require immediate follow-up. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617247&lang=en > language: en > subject: Mental Health Concepts > category: PSI ## Question Stage 1 — Recognize cues. The nurse reviews the admission assessment. Highlight the findings that require immediate follow-up. A 46-year-old adult with bipolar I disorder takes lithium carbonate 600 mg twice daily and hydrochlorothiazide for hypertension. For 3 days the client has had vomiting and diarrhea, kept taking lithium, and used ibuprofen every 6 hours for cramps. A family member brings the client to the emergency department because of confusion and unsteady walking. Clinic note from last month: mood stable, HR 72/min and regular, fine hand tremor for several years, and wakes to urinate 2-3 times nightly for years. Current assessment: coarse tremor in both hands, worse on reaching; speech is slurred; walks with a wide base and lurches to the side; cannot state the month or the hospital name; denies thoughts of self-harm; denies racing thoughts or reduced sleep. BP 98/62 mm Hg, HR 54/min and irregular, RR 18/min, temperature 37.6 C (99.7 F), SpO2 98% on room air. Mucous membranes are dry. Capillary glucose 104 mg/dL. The family reports last alcohol use at a wedding 10 days ago. Serum lithium and a metabolic panel are pending. ## Explanation The new coarse tremor (compared with the documented long-standing fine tremor), ataxic gait, disorientation, and a slow irregular rhythm (baseline 72 and regular) are new neurologic and cardiac findings that fit lithium toxicity and need immediate action. The fine tremor and nocturia are chronic, expected lithium effects already documented last month, and the low-grade temperature, glucose, alcohol history, and absent mania or suicidal thinking point away from the look-alike explanations rather than toward danger. ## In-depth explanation Quick answer Select the new coarse tremor, the wide-based lurching gait, disorientation, and HR 54/min and irregular. Why this is correct The chart gives a baseline: last month the client had a fine tremor, nocturia, and a regular HR of 72. A tremor that has become coarse, cerebellar ataxia, new disorientation, and new bradycardia with irregularity are changes from that baseline and match moderate-to-severe lithium neurotoxicity and cardiac conduction effects in a client who is volume depleted and taking a thiazide and an NSAID. Easy analogy or mental picture Think of the baseline note as last month's photograph. The nurse is looking for what is different in today's picture, not for everything that is abnormal in both pictures. Memory hook Fine tremor = the drug is present. Coarse tremor + wobbly gait + confusion = the drug is too high. NCLEX decision rule When a client on a narrow-therapeutic-range drug presents with abnormal findings, compare each finding with the documented baseline; new neurologic or rhythm changes take priority over chronic expected adverse effects. Why the other choices are wrong The fine tremor and years of nocturia are tempting because they are lithium adverse effects, but they are chronic and documented, so they do not signal the acute toxicity. Temperature 37.6 C fits the gastroenteritis and is not the hyperthermia of serotonin toxicity or NMS. Glucose 104 mg/dL excludes hypoglycemia as the cause of confusion, and alcohol use 10 days ago is too remote to explain intoxication or withdrawal. Absent self-harm thoughts and absent mania are important psychiatric safety findings, but they do not lower the medical urgency. SpO2 98% is reassuring. References 1StatPearls: Lithium Toxicity (NCBI Bookshelf)Neurologic signs (coarse tremor, ataxia, confusion) and bradycardia/conduction effects in lithium toxicity; dehydration, thiazides, and NSAIDs raise lithium levels 2DailyMed: Lithium carbonate prescribing informationLabel warnings on toxicity signs and interacting drugs (diuretics, NSAIDs) and sodium/fluid depletion ## Clinical scenario Case update A client taking maintenance lithium, a thiazide, and frequent ibuprofen arrives after 3 days of vomiting and diarrhea with new confusion and gait change. ## Key concepts - **Lithium neurotoxicity** — Central nervous system toxicity from excess lithium that produces coarse tremor, ataxia, dysarthria, and confusion and can progress to seizures. - **Cerebellar ataxia** — Loss of coordinated movement that produces a wide-based, lurching gait and is a classic sign of rising lithium toxicity. - **Baseline comparison** — Judging a finding against the client's documented prior state so that chronic expected effects are separated from new changes. ## Related questions - [A client hospitalized for depression says, "My family would be better off without me." 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