Board Review: Lithium

Quiz, Review Content & Patient Scenarios

Today’s post is the first board review post. This style of post will be published every Friday. Today’s version will include 10 practice questions, a brief review of content covered & then a related patient scenario. While this post is arguably designed for the student PMHNP, practicing PMHNPs will likely enjoy the patient scenarios as well. Before getting into the practice questions let’s review our disclaimer:

DISCLAIMER

The content provided in this Substack post is for entertainment and informational purposes only and is not intended to serve as medical advice. The views and opinions expressed herein are those of the writer and should not be taken as definitive or authoritative. Readers should not rely solely on the information provided in this post to make decisions about patient care. Instead, use this content as a starting point for further research and consult a qualified healthcare professional before making any changes to treatment or medication regimens.

Okay with that said, let’s do some practice questions.

Go ahead and go through each question initially, below is the quiz a second time with the correct answers and rationales attached.

1. A psychiatric PMHNP is reviewing a patient's medication regimen and notes that the patient is taking lithium. What is the therapeutic range for serum lithium levels?

   1. 0.2-0.8 mEq/L

   2. 0.6-1.2 mEq/L

   3. 1.0-1.5 mEq/L

   4. 1.2-2.0 mEq/L

2. A patient who is taking lithium for bipolar disorder presents with severe nausea, unsteady gait, and coarse hand tremors. The PMHNP recognizes these as symptoms of lithium toxicity. Which of the following symptoms is NOT typically associated with lithium toxicity?

   1. Severe nausea

   2. Unsteady gait

   3. Increased appetite

   4. Coarse hand tremors

3. A PMHNP is reviewing the management of various mental health disorders. For which of the following conditions is lithium considered the gold standard treatment?

   1. Major depressive disorder

   2. Mania

   3. Generalized anxiety disorder

   4. Schizophrenia

4. A PMHNP is preparing to initiate lithium therapy for a patient aged 50 years or older. Which baseline lab should be checked before starting the medication?

   1. TSH

   2. Creatinine

   3. EKG

   4. HCG

5. A patient taking lithium for bipolar disorder presents with hand tremors. Which of the following types of tremors is associated with lithium toxicity?

   1. Fine hand tremors

   2. Coarse hand tremors

   3. Weight gain

   4. Pruritis

6. A PMHNP is educating a patient about factors that can cause an increase in lithium levels. Which of the following can lead to elevated lithium levels?

   1. Dehydration and hypernatremia

   2. Hydration and hyponatremia

   3. Dehydration and hyponatremia

   4. Hydration and hypernatremia

7. A PMHNP is monitoring a patient taking lithium for bipolar disorder. Which of the following should be monitored to detect potential kidney issues?

   1. TSH levels

   2. Urinalysis for proteins

   3. EKG

   4. Liver function tests (LFTs)

8. A 45-year-old female patient is starting lithium treatment for bipolar disorder. Which test should be performed as part of the baseline labs?

   1. TSH

   2. EKG

   3. HCG

   4. AST and ALT

9. Which of the following symptoms would NOT be expected in a patient experiencing lithium toxicity?

   1. Severe nausea

   2. Polyuria

   3. Coarse hand tremors

   4. Heart palpitations

10. A healthcare provider is counseling a pregnant patient about the risks associated with psychotropic medications. Which of the following medications is associated with an increased risk of Ebstein anomaly, especially during the first trimester

    1. Benzodiazepines

    2. Tegretol

    3. Lithium

    4. Depakote

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1. A psychiatric PMHNP is reviewing a patient's medication regimen and notes that the patient is taking lithium. What is the therapeutic range for serum lithium levels?

   1. 0.2-0.8 mEq/L

   2. 0.6-1.2 mEq/L

   3. 1.0-1.5 mEq/L

   4. 1.2-2.0 mEq/L

Correct Answer: b) 0.6-1.2 mEq/L

Rationale: The therapeutic range for serum lithium levels is 0.6-1.2 mEq/L (b). Levels below or above this range are not considered therapeutic and may lead to suboptimal treatment or toxicity. The other options (a, c, d) do not represent the correct therapeutic range for serum lithium levels.

2. A patient who is taking lithium for bipolar disorder presents with severe nausea, unsteady gait, and coarse hand tremors. The PMHNP recognizes these as symptoms of lithium toxicity. Which of the following symptoms is NOT typically associated with lithium toxicity?

   1. Severe nausea

   2. Unsteady gait

   3. Increased appetite

   4. Coarse hand tremors

Correct Answer: c) Increased appetite

Rationale: Increased appetite (c) is not typically associated with lithium toxicity. Symptoms of lithium toxicity commonly include severe nausea (a), unsteady gait (b), and coarse hand tremors (d). It is crucial for healthcare providers to monitor lithium levels and adjust dosages accordingly to prevent toxicity.

3. A PMHNP is reviewing the management of various mental health disorders. For which of the following conditions is lithium considered the gold standard treatment?

   1. Major depressive disorder

   2. Mania

   3. Generalized anxiety disorder

   4. Schizophrenia

Correct Answer: b) Mania

Rationale: Lithium is considered the gold standard treatment for mania (b) in patients with bipolar disorder. It helps stabilize mood and prevent manic episodes. Major depressive disorder (a) is typically treated with antidepressants, such as SSRIs or SNRIs. Generalized anxiety disorder (c) is commonly managed with medications like SSRIs, benzodiazepines, or buspirone. Schizophrenia (d) is primarily treated with antipsychotic medications.

4. A PMHNP is preparing to initiate lithium therapy for a patient aged 50 years or older. Which baseline lab should be checked before starting the medication?

   1. TSH

   2. Creatinine

   3. EKG

   4. HCG

Correct Answer: c) EKG

Rationale: Before initiating lithium therapy for patients aged 50 and older, an EKG (c) should be checked as a baseline assessment. This is due to the potential cardiac side effects of lithium, particularly in older adults. TSH (a) and creatinine (b) may also be monitored during lithium therapy, but they are not specific to older adults. HCG (d) is a pregnancy hormone and not relevant in this context.

5. A patient taking lithium for bipolar disorder presents with hand tremors. Which of the following types of tremors is associated with lithium toxicity?

   1. Fine hand tremors

   2. Coarse hand tremors

   3. Weight gain

   4. Pruritis

Correct Answer: b) Coarse hand tremors

Rationale: Coarse hand tremors (b) are associated with lithium toxicity. Fine hand tremors (a) are a common side effect of lithium but do not necessarily indicate toxicity. Weight gain (c) and pruritis (d) are also potential side effects of lithium but are not directly related to toxicity. It is crucial for healthcare providers to monitor lithium levels and adjust dosages accordingly to prevent toxicity.

6. A PMHNP is educating a patient about factors that can cause an increase in lithium levels. Which of the following can lead to elevated lithium levels?

   1. Dehydration and hypernatremia

   2. Hydration and hyponatremia

   3. Dehydration and hyponatremia

   4. Hydration and hypernatremia

Correct Answer: c) Dehydration and hyponatremia

Rationale: Dehydration and hyponatremia (c) can cause an increase in lithium levels. This occurs because lithium is primarily excreted by the kidneys, and these conditions can lead to decreased lithium clearance. Dehydration and hypernatremia (a), hydration and hyponatremia (b), and hydration and hypernatremia (d) are not accurate combinations for factors that increase lithium levels. It is essential for healthcare providers to educate patients on the importance of maintaining proper hydration and electrolyte balance while taking lithium.

7. A PMHNP is monitoring a patient taking lithium for bipolar disorder. Which of the following should be monitored to detect potential kidney issues?

   1. TSH levels

   2. Urinalysis for proteins

   3. EKG

   4. Liver function tests (LFTs)

Correct Answer: b) Urinalysis for proteins

Rationale: Urinalysis for proteins (b) should be monitored in a patient taking lithium to detect potential kidney issues. This is because lithium is primarily excreted by the kidneys and can cause renal impairment. TSH levels (a), EKG (c), and Liver function tests (LFTs) (d) are not specifically related to detecting kidney issues in patients taking lithium.

8. A 26-year-old female patient is starting lithium treatment for bipolar disorder. Which test should be performed as part of the baseline labs?

   1. TSH

   2. EKG

   3. HCG

   4. AST and ALT

Correct Answer: c) HCG

Rationale: An HCG test (c) should be performed for all female patients aged 12-51 before starting lithium treatment to rule out pregnancy. Lithium is classified as a pregnancy category D drug and can cause harm to a developing fetus. TSH (a), EKG (b), and AST and ALT (d) are other tests that may be performed during lithium therapy, but they are not specifically related to ruling out pregnancy.

9. Which of the following symptoms would NOT be expected in a patient experiencing lithium toxicity?

   1. Severe nausea

   2. Polyuria

   3. Coarse hand tremors

   4. Heart palpitations

Correct answer: polyuria (b)

Rationale: Polyuria (b) is a side effect of lithium but is not specifically associated with lithium toxicity. Severe nausea (a), coarse hand tremors (c), and heart palpitations (d) are all symptoms of lithium toxicity.

10. A healthcare provider is counseling a pregnant patient about the risks associated with psychotropic medications. Which of the following medications is associated with an increased risk of Ebstein anomaly, especially during the first trimester

    1. Benzodiazepines

    2. Tegretol

    3. Lithium

    4. Depakote

Correct Answer: c) Lithium

Rationale: Lithium (c) is associated with an increased risk of Ebstein anomaly, especially during the first trimester. Ebstein anomaly is a rare heart defect that can cause significant complications for the newborn. Benzodiazepines (a), Tegretol (b), and Depakote (d) carry different risks during pregnancy but are not specifically associated with an increased risk of Ebstein anomaly.

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Board Review Lithium Quiz

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Content Review: Lithium in the management of Bipolar d/o

1. Bipolar disorder is a mood disorder characterized by episodes of mania and depression.

2. One common medication used in the management of bipolar disorder is lithium.

3. This content review will provide an overview of the therapeutic ranges, side effects, and considerations for lithium, divided into four parts.

Part 1: Lithium - Therapeutic Range, Side Effects, and Toxicity

A. Therapeutic Range

1. The therapeutic range for serum lithium levels is 0.6-1.2 mEq/L.

2. Lithium is known to have a narrow therapeutic range, which means levels below or above this range may lead to suboptimal treatment or toxicity.

B. Side Effects

1. Common side effects of lithium include fine hand tremors, weight gain, and pruritus.

C. Lithium Toxicity

1. Symptoms of lithium toxicity include severe nausea, unsteady gait, and coarse hand tremors.

2. Coarse hand tremors are associated with lithium toxicity, while fine hand tremors are a common side effect but do not necessarily indicate toxicity.

Part 2: Lithium - Factors Affecting Lithium Levels, Kidney Considerations, and Pregnancy Considerations

A. Factors Affecting Lithium Levels

1. Dehydration and hyponatremia:

   • Both conditions can cause an increase in lithium levels.

   • This occurs because lithium is primarily excreted by the kidneys, and these conditions can lead to decreased lithium clearance.

   • Healthcare providers should educate patients on the importance of maintaining proper hydration and electrolyte balance while taking lithium to prevent elevated lithium levels.

B. Kidney Considerations

1. Monitoring kidney function:

   • Urinalysis for proteins should be monitored in patients taking lithium to detect potential kidney issues.

   • Lithium is primarily excreted by the kidneys and can cause renal impairment.

   • Regular monitoring of kidney function is important to ensure patient safety and adjust the lithium dosage as needed.

   • A specific concern is lithium induced diabetes insipidus

C. Pregnancy Considerations

1. Lithium use during pregnancy:

   • Lithium is classified as a pregnancy category D drug and can cause harm to a developing fetus.

   • An HCG test should be performed for all female patients aged 12-51 before starting lithium treatment to rule out pregnancy.

   • If a patient becomes pregnant while taking lithium, healthcare providers must weigh the potential risks and benefits of continuing lithium therapy during pregnancy.

Part 3: Uses, Monitoring, and Management

A. Uses

1. Lithium is considered the gold standard treatment for mania.

B. Monitoring Parameters

1. Lithium:

   • Therapeutic range: 0.6-1.2 mEq/L

   • Baseline labs: TSH, creatinine, EKG (for patients aged 50 years and older), and HCG (for female patients aged 12-51)serum lithium levels are typically monitored every 3-6 months once stable.

   • Ongoing monitoring: serum lithium levels, renal function, and thyroid function

Patient Scenario: Lithium

Jasmine is a 28-year-old female who was recently diagnosed with Bipolar I Disorder after experiencing a severe manic episode. She was prescribed lithium to help stabilize her mood and prevent future episodes. Jasmine has been taking lithium for two months, and her serum lithium levels have been stable within the therapeutic range (0.6-1.2 mEq/L). She is currently taking 900 mg of lithium daily, divided into three doses.

During Jasmine's most recent visit to her psychiatric mental health nurse practitioner (PMHNP), she reports experiencing frequent mild hand tremors, increased thirst, and significant weight gain. She also mentions that she has been feeling more fatigued than usual and her hands and feet have been cold.

Upon further assessment, the PMHNP notices that Jasmine's skin is dry and her hair appears thin and brittle. The PMHNP suspects that Jasmine might be experiencing hypothyroidism, a potential side effect of lithium therapy. The PMHNP orders a thyroid-stimulating hormone (TSH) test, which confirms that Jasmine has developed hypothyroidism.

The PMHNP must make adjustments to Jasmine's treatment plan to address her hypothyroidism, side effects, and potential risk factors for lithium toxicity. The first step might be to consult with an endocrinologist to manage Jasmine's hypothyroidism, which could involve starting her on a thyroid replacement medication like levothyroxine.

To address the hand tremors, the PMHNP could consider reducing Jasmine's lithium dose or adding a beta-blocker such as propranolol to manage this side effect. They might also recommend that Jasmine engage in regular physical activity and adopt a healthier diet to help manage her weight gain and promote overall well-being.

The PMHNP emphasizes the importance of maintaining proper hydration and electrolyte balance to Jasmine, recommending that she monitor her fluid intake. They might also consider more frequent monitoring of Jasmine's lithium levels and kidney function, especially during the initial adjustment period.

Given the multiple changes in Jasmine's treatment plan, it is crucial for the PMHNP to closely monitor her progress, side effects, and response to the new interventions. Regular follow-up appointments and ongoing communication between Jasmine and her healthcare team will be essential to ensure her safety and well-being as she continues her journey towards stability and recovery.

There you have it. The goal is to follow this outline of questions, then review & related scenario every Friday.