,
,Question 1 (NGN Bow-Tie Question)
Difficulty: Level 3 (High Acuity)
A 45-year-old male with Bipolar I disorder is brought to the emergency department by his wife.
He has been taking lithium carbonate 900 mg/day. The wife reports he has had severe vomiting
and diarrhea for the past 48 hours due to a "stomach bug" and has not been able to keep food
or water down. He is now exhibiting a coarse hand tremor, muscle twitching, slurred speech,
and confusion. His last lithium level drawn 2 weeks ago was 0.9 mEq/L.
Complete the Bow-Tie:
• Condition: What is the most likely condition the patient is experiencing?
• Risk Factors (Select 2): What factors contributed to this acute episode?
• Complication: What is the most immediate life-threatening complication to monitor for?
• Nursing Action: What is the priority nursing intervention?
Risk
Complication (Select Nursing
Factors (Select Condition (Select 1)
1) Action (Select 1)
2)
A) Administer
A) Dehydration A) Lithium toxicity A) Hyponatremia
Kayexalate
B) Hold the next dose
B) B) Serotonin B) Seizures / Cardiac
and draw a stat
Hyponatremia syndrome dysrhythmias
lithium level
C) Extrapyramidal C) Restrict oral fluids
C) Polyuria C) Hepatic failure
symptoms to 1,000 mL/day
D) Neuroleptic
D) Drug-drug D) Administer Ativan
malignant D) DVT
interaction to stop the tremor
syndrome
Rationale for Question 1:
, • Condition (Lithium Toxicity): Vomiting/diarrhea leads to sodium and water loss. The
kidneys reabsorb sodium in exchange for lithium, causing lithium retention. A sudden
drop in renal perfusion pushes lithium levels into the toxic range (>1.5 mEq/L). Coarse
tremor, confusion, and GI distress are hallmark signs.
• Risk Factors:
o A) Dehydration is correct (fluid loss from the GI bug reduces GFR).
o B) Hyponatremia is correct (low serum sodium causes the kidneys to retain
lithium, spiking the level).
o C) Polyuria is a side effect of lithium, not a risk factor for acute toxicity in this
scenario.
o D) Drug-drug is not indicated here.
• Complication (Seizures/Cardiac dysrhythmias): Severe lithium toxicity (>2.5 mEq/L) can
cause neurological compromise (seizures, coma) and fatal ventricular dysrhythmias.
• Nursing Action (Hold dose and draw stat level): The priority is to immediately stop the
exogenous lithium and confirm the toxic level. IV fluids for rehydration will be
started after the level is drawn. Kayexalate is used for hyperkalemia, not lithium.
Question 2 (NGN Multiple Response / SATA)
Difficulty: Level 3
A 68-year-old patient with Major Depressive Disorder is started on phenelzine (Nardil), a
Monoamine Oxidase Inhibitor (MAOI). The nurse is providing dietary and medication teaching.
Which statements by the patient indicate a correct understanding of the dietary restrictions
required to prevent a hypertensive crisis? (Select all that apply.)
1. "I need to avoid aged cheeses like cheddar and blue cheese while taking this
medication."
2. "It is safe for me to eat a banana or an avocado as long as I eat it with breakfast."
3. "I should not drink red wine or tap beer, but small amounts of bottled beer are okay."
4. "If I suddenly develop a severe headache or nausea, I should take my blood pressure
immediately."
,Question 1 (NGN Bow-Tie Question)
Difficulty: Level 3 (High Acuity)
A 45-year-old male with Bipolar I disorder is brought to the emergency department by his wife.
He has been taking lithium carbonate 900 mg/day. The wife reports he has had severe vomiting
and diarrhea for the past 48 hours due to a "stomach bug" and has not been able to keep food
or water down. He is now exhibiting a coarse hand tremor, muscle twitching, slurred speech,
and confusion. His last lithium level drawn 2 weeks ago was 0.9 mEq/L.
Complete the Bow-Tie:
• Condition: What is the most likely condition the patient is experiencing?
• Risk Factors (Select 2): What factors contributed to this acute episode?
• Complication: What is the most immediate life-threatening complication to monitor for?
• Nursing Action: What is the priority nursing intervention?
Risk
Complication (Select Nursing
Factors (Select Condition (Select 1)
1) Action (Select 1)
2)
A) Administer
A) Dehydration A) Lithium toxicity A) Hyponatremia
Kayexalate
B) Hold the next dose
B) B) Serotonin B) Seizures / Cardiac
and draw a stat
Hyponatremia syndrome dysrhythmias
lithium level
C) Extrapyramidal C) Restrict oral fluids
C) Polyuria C) Hepatic failure
symptoms to 1,000 mL/day
D) Neuroleptic
D) Drug-drug D) Administer Ativan
malignant D) DVT
interaction to stop the tremor
syndrome
Rationale for Question 1:
, • Condition (Lithium Toxicity): Vomiting/diarrhea leads to sodium and water loss. The
kidneys reabsorb sodium in exchange for lithium, causing lithium retention. A sudden
drop in renal perfusion pushes lithium levels into the toxic range (>1.5 mEq/L). Coarse
tremor, confusion, and GI distress are hallmark signs.
• Risk Factors:
o A) Dehydration is correct (fluid loss from the GI bug reduces GFR).
o B) Hyponatremia is correct (low serum sodium causes the kidneys to retain
lithium, spiking the level).
o C) Polyuria is a side effect of lithium, not a risk factor for acute toxicity in this
scenario.
o D) Drug-drug is not indicated here.
• Complication (Seizures/Cardiac dysrhythmias): Severe lithium toxicity (>2.5 mEq/L) can
cause neurological compromise (seizures, coma) and fatal ventricular dysrhythmias.
• Nursing Action (Hold dose and draw stat level): The priority is to immediately stop the
exogenous lithium and confirm the toxic level. IV fluids for rehydration will be
started after the level is drawn. Kayexalate is used for hyperkalemia, not lithium.
Question 2 (NGN Multiple Response / SATA)
Difficulty: Level 3
A 68-year-old patient with Major Depressive Disorder is started on phenelzine (Nardil), a
Monoamine Oxidase Inhibitor (MAOI). The nurse is providing dietary and medication teaching.
Which statements by the patient indicate a correct understanding of the dietary restrictions
required to prevent a hypertensive crisis? (Select all that apply.)
1. "I need to avoid aged cheeses like cheddar and blue cheese while taking this
medication."
2. "It is safe for me to eat a banana or an avocado as long as I eat it with breakfast."
3. "I should not drink red wine or tap beer, but small amounts of bottled beer are okay."
4. "If I suddenly develop a severe headache or nausea, I should take my blood pressure
immediately."
