A nurse is admitting a client to the mental health unit. Exhibits The nurse is developing a plan of care for the client. Which of the following interventions should the nurse include? (Select all that apply.)

Choice A: Set up a dietary consult for a low-sodium diet. Reason: While a low-sodium diet is generally recommended for clients with heart failure to manage fluid retention and blood pressure, it is not the immediate priority in this scenario. The client’s current symptoms and lab results indicate lithium toxicity, which requires more urgent interventions. Choice B: Notify the provider of potential medication interactions. Reason: The client is taking lithium and furosemide, which can interact and increase the risk of lithium toxicity. Furosemide, a diuretic, can cause dehydration and electrolyte imbalances, exacerbating lithium toxicity. Notifying the provider is crucial to address these interactions and adjust medications accordingly. Choice C: Withhold next dose of lithium. Reason: The client’s lithium level is 2.2 mEq/L, which is above the therapeutic range (0.8 to 1.2 mEq/L) and indicates toxicity. Symptoms such as vomiting, diarrhea, muscle twitching, slurred speech, and drowsiness further support this. Withholding the next dose of lithium is necessary to prevent worsening toxicity2. Choice D: Educate the client about the need for hemodialysis. Reason: In cases of severe lithium toxicity, hemodialysis may be required to rapidly remove lithium from the body. Given the client’s high lithium level and symptoms, educating them about this potential treatment is important. Choice E: Discuss contraception. Reason: While discussing contraception is important for clients on lithium due to potential teratogenic effects, it is not an immediate priority in this acute situation. The focus should be on addressing the lithium toxicity and stabilizing the client. Choice F: Assess need for and administer prochlorperazine PRN. Reason: The client has been experiencing nausea and vomiting, which are symptoms of lithium toxicity2. Administering prochlorperazine can help manage these symptoms and provide relief. However, it is essential to monitor the client closely due to potential interactions with other medications.