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Two days after his last drink, a male alcoholic client becomes agitated and yells at his wife and children, 'Stay away from me!' His vital signs are elevated. What nursing diagnosis has the highest priority?
- A. High risk for social isolation.
- B. Altered parenting.
- C. Ineffective individual coping.
- D. High risk for injury.
Correct Answer: D
Rationale: The correct answer is 'High risk for injury.' The client's agitation, elevated vital signs, and aggressive behavior pose a threat to himself and his family. Addressing the risk for injury is the priority to ensure the safety of all individuals involved. Choices A, B, and C are not the highest priority in this scenario. 'High risk for social isolation' does not address the immediate physical safety concern. 'Altered parenting' and 'Ineffective individual coping' are important but not as urgent as the risk for injury in this situation.
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Based on non-compliance with the medication regimen, an adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate). What is most important to teach the client and family about this change in medication regimen?
- A. Signs and symptoms of extrapyramidal effects (EPS).
- B. Information about substance abuse and schizophrenia.
- C. The effects of alcohol and drug interaction.
- D. The availability of support groups for those with dual diagnoses.
Correct Answer: C
Rationale: Teaching about the effects of alcohol and drug interaction is crucial to prevent adverse reactions, especially with the long-acting injectable form of fluphenazine. Understanding how alcohol and drugs can interact with the medication will help the client and family to ensure medication effectiveness and avoid potential harmful effects. Choices A, B, and D are not the most important to teach in this scenario. While knowing the signs and symptoms of extrapyramidal effects (EPS) is important, understanding the effects of alcohol and drug interaction is more critical in this specific situation. Information about substance abuse and schizophrenia, as well as the availability of support groups, are essential aspects of care but are not the primary focus when switching to a long-acting injectable medication due to non-compliance.
A client with panic disorder is experiencing a panic attack. What is the nurse's priority intervention?
- A. Encourage the client to breathe slowly and deeply.
- B. Ask the client to describe the sensations they are experiencing.
- C. Encourage the client to focus on a calming image.
- D. Administer a PRN dose of lorazepam (Ativan).
Correct Answer: A
Rationale: The correct answer is A. Encouraging slow, deep breathing is the priority intervention during a panic attack as it can help reduce the physiological symptoms and assist the client in regaining control. This technique can help decrease hyperventilation and promote relaxation. Choice B, asking the client to describe sensations, may be beneficial after the panic attack has subsided to gain insight into triggers or manifestations. Choice C, encouraging the client to focus on a calming image, can be helpful in managing anxiety but may not be as effective during the acute phase of a panic attack. Choice D, administering a PRN dose of lorazepam (Ativan), should only be considered if the client does not respond to initial non-pharmacological interventions or if the symptoms are severe and unmanageable.
A nurse determines that the wife of an alcoholic client is benefitting from attending an Al-Anon group when the nurse hears the wife say:
- A. I no longer feel that I deserve the meetings my husband inflicts on me.
- B. My attendance at the meetings has helped me to see that I provoke my husband's violence.
- C. I enjoy attending the meetings because they get me out of the house and away from my husband.
- D. I can tolerate my husband's destructive behaviors now that I know they are common with alcoholics.
Correct Answer: A
Rationale: Choice A is the correct answer as the statement indicates the wife understands that her husband's behavior is not her fault and is benefitting from the group support. Choice B is incorrect as it suggests self-blame rather than recognizing the husband's responsibility. Choice C is incorrect as the benefit is related to emotional support and understanding, not just getting away from the husband. Choice D is incorrect as tolerating destructive behaviors is not a healthy outcome of attending support groups.
A client is preparing to attend a Gamblers Anonymous meeting for the first time. The prototype used by this group is the 12-step program developed by Alcoholics Anonymous. Number in order of priority how the steps would be addressed.
- A. Admitting to oneself and to another human being the exact nature of one's wrongs
- B. Acknowledging that one is entirely ready to have his or her defects of character removed
- C. Admitting that oneself is powerless over gambling and that one's life has become unmanageable
- D. Making an effort to practice the 12-step principles in all affairs, and to carry out this message to other compulsive gamblers
Correct Answer: D
Rationale: The correct order of addressing the 12-step program typically begins with admitting powerlessness over the addiction and recognizing the unmanageability of one's life (Choice C). Following this, individuals move towards acknowledging their wrongs and sharing them with others (Choice A), then being ready to work on changing their character defects (Choice B), and finally, integrating the 12-step principles into their daily lives and helping others (Choice D). Choices A, B, and C are important steps in the program but come after admitting powerlessness and unmanageability, which is why Choice D is the correct answer.
A client with bipolar disorder is admitted to the psychiatric unit in a manic state. What is the most therapeutic nursing intervention?
- A. Allow the client to engage in any activity they choose.
- B. Provide a structured environment with reduced stimuli.
- C. Encourage the client to express their thoughts freely.
- D. Place the client in a room with another client for socialization.
Correct Answer: B
Rationale: During a manic state, individuals with bipolar disorder may exhibit hyperactivity, impulsivity, and reduced need for sleep. Providing a structured environment with reduced stimuli is the most therapeutic nursing intervention as it can help manage the client's excessive energy and prevent overstimulation. Choice A is incorrect as allowing the client to engage in any activity they choose may exacerbate their symptoms or lead to risky behaviors. Choice C, encouraging the client to express their thoughts freely, may not be appropriate during a manic state as it can further escalate their racing thoughts. Choice D, placing the client in a room with another client for socialization, may not be beneficial during a manic episode as it could increase stimulation and potentially lead to agitation.