History and PhysicalNurses' NotesVital SignsProvider Prescriptions

Day 1, 0900:

A 52-year-old client brought to emergency department by adult child. Client is alert and oriented to person and time but does not know where they are. No history of substance use according to client's adult child. Client exhibits constant movements and poor concentration. Hair and clothing are unclean. Appears to be listening to unseen others. Skin turgor poor.

Day 1, 0915:

The client's adult child reports the client has not slept for 2 days and has become obsessed with cleaning the house and hosting parties. At times the client is overly joyous and has a very elevated sense of self-confidence. The adult child states that the client has also demonstrated very impulsive spending habits and expresses concern about the client giving away large sums of money to others.

The client's speech is very pressured, disorganized, and loud. Client unable to recall the last time they ate.

0930:

Client questioned about their hallucinations and states that the same person has been following them around inside and outside the house for days. Client asks the person what they want but never receives an answer. Client states that this person has never told them to do anything; they just stare and smile.

1015:

Client's erratic behavior continues with loud outbursts, continues to get out of bed and pace around the unit. Prescription received to admit client to inpatient mental health unit.

Day 1, 0905:

Temperature 37.1° C (98.8° F)

Heart rate 120/min

Respiratory rate 19/min

BP 138/88 mm Hg

Oxygen saturation 98% on room air

1030:

Temperature 37.1° C (98.8° F)

Heart rate 105/min

Respiratory rate 18/min

BP 140/86 mm Hg

Oxygen saturation 98% on room air

Day 1, 1100:

Lithium carbonate 600 mg PO BID

The nurse is continuing to care for the client.

The nurse is providing teaching about lithium to the client and the client's adult child. Select the 3 statements the nurse should include.