What should the nurse do if the client becomes agitated after evaluating a high lithium level?

What should the nurse do if the client becomes agitated after evaluating a high lithium level?

• A. Provide reassurance and comfort
• B. Initiate a seclusion protocol
• C. Notify mental health staff
• D. Offer distraction techniques

Answer: (B)

In a situation where a client becomes agitated due to a high lithium level, the most appropriate response involves prioritizing the immediate safety and stability of the client. Initiating a seclusion protocol is correct because a high lithium level can lead to significant side effects, including neurological disturbances and mood changes, which may exacerbate agitation. Seclusion can be a necessary intervention to ensure the individual does not harm themselves or others, allowing for a controlled environment to de-escalate the situation. While providing reassurance and comfort, notifying mental health staff, and offering distraction techniques are all valid supportive strategies in addressing agitation, they may not adequately manage the risk associated with the underlying medical condition in this context. Seclusion serves as a critical step to ensure necessary monitoring and treatment can be administered safely, given that the client’s mental state may be compromised by the effects of high lithium levels.

In a situation where a client becomes agitated due to a high lithium level, the most appropriate response involves prioritizing the immediate safety and stability of the client. Initiating a seclusion protocol is correct because a high lithium level can lead to significant side effects, including neurological disturbances and mood changes, which may exacerbate agitation. Seclusion can be a necessary intervention to ensure the individual does not harm themselves or others, allowing for a controlled environment to de-escalate the situation.

While providing reassurance and comfort, notifying mental health staff, and offering distraction techniques are all valid supportive strategies in addressing agitation, they may not adequately manage the risk associated with the underlying medical condition in this context. Seclusion serves as a critical step to ensure necessary monitoring and treatment can be administered safely, given that the client’s mental state may be compromised by the effects of high lithium levels.