Nokea
A client with alcohol use disorder is admitted for detoxification. The nurse should monitor for which early sign of alcohol withdrawal?
- A. Seizures
- B. Visual hallucinations
- C. Tremors
- D. Delirium tremens
Correct Answer: C
Rationale: Tremors are an early sign of alcohol withdrawal. They are caused by hyperactivity of the autonomic nervous system and are a common symptom during the early stages of withdrawal. Monitoring tremors is crucial as they can progress to more severe symptoms if not managed effectively. Seizures (Choice A) typically occur later in the withdrawal process and are a more severe symptom. Visual hallucinations (Choice B) usually manifest after tremors and are considered a mid-stage symptom. Delirium tremens (Choice D) is a severe form of alcohol withdrawal that typically occurs 2-3 days after the last drink, characterized by confusion, disorientation, and severe autonomic hyperactivity.
You may also like to solve these questions
A nurse is caring for a client with depression who is prescribed fluoxetine (Prozac). The client reports difficulty sleeping. What is the most appropriate nursing intervention?
- A. Encourage the client to take short naps during the day.
- B. Suggest the client drink a warm beverage before bedtime.
- C. Recommend the client exercise immediately before bedtime.
- D. Advise the client to take a sleep aid nightly.
Correct Answer: B
Rationale: The most appropriate nursing intervention for a client with difficulty sleeping due to depression and prescribed fluoxetine is to suggest the client drink a warm beverage before bedtime. This intervention can promote relaxation and help establish a bedtime routine, potentially improving sleep quality. Encouraging short naps during the day (Choice A) may disrupt the client's nighttime sleep schedule. Recommending exercise immediately before bedtime (Choice C) can have a stimulating effect, making it harder for the client to fall asleep. Advising the client to take a sleep aid nightly (Choice D) should only be done under the guidance of a healthcare provider due to potential interactions with fluoxetine.
A client who has just been sexually assaulted is calm and quiet. The nurse analyzes this behavior as indicating which defense mechanism?
- A. Denial
- B. Projection
- C. Rationalization
- D. Intellectualization
Correct Answer: A
Rationale: The correct answer is A: Denial. In this situation, the client's calm and quiet demeanor after a traumatic event like sexual assault may indicate denial, a defense mechanism where the individual refuses to acknowledge the reality of the distressing event. Choice B, Projection, involves attributing one's thoughts or feelings to others. Choice C, Rationalization, is a defense mechanism where logical reasoning is used to justify behaviors or feelings. Choice D, Intellectualization, is a defense mechanism where excessive reasoning or logic is used to avoid uncomfortable emotions.
A client with a leg amputation is upset about his appearance. The LPN/LVN intends to address which most closely associated psychosocial problem?
- A. Inability to be mobile
- B. Isolating self from others
- C. Inability to tolerate activity
- D. Concern about body persona
Correct Answer: D
Rationale: The correct answer is D. A client with a leg amputation being upset about his appearance is most closely associated with concerns about body image and self-perception. This individual may be worried about how others perceive them, impacting their self-esteem and overall well-being. Choices A, B, and C are incorrect because the primary psychosocial issue in this scenario is related to body image and self-perception, not mobility, social isolation, or activity tolerance.
A female client with post-traumatic stress disorder (PTSD) has been experiencing flashbacks. Which intervention should the nurse implement to help the client?
- A. Encourage the client to talk about the trauma.
- B. Advise the client to avoid triggers that cause flashbacks.
- C. Help the client stay grounded in the present moment.
- D. Refer the client to group therapy for PTSD.
Correct Answer: C
Rationale: The correct intervention for a client with PTSD experiencing flashbacks is to help them stay grounded in the present moment. This technique can reduce the intensity of flashbacks and provide a sense of safety. Encouraging the client to talk about the trauma (Choice A) may exacerbate the symptoms and should be done cautiously under professional guidance. Advising the client to avoid triggers (Choice B) is important, but solely relying on avoidance may not address the underlying issues. Referring the client to group therapy (Choice D) can be beneficial, but in the immediate context of managing flashbacks, grounding techniques are more appropriate.
A client with bipolar disorder is prescribed valproic acid (Depakote). What is the most important laboratory test for the LPN/LVN to monitor?
- A. Liver function tests.
- B. Kidney function tests.
- C. Thyroid function tests.
- D. Complete blood count.
Correct Answer: A
Rationale: The correct answer is A: Liver function tests. Monitoring liver function tests is crucial for clients prescribed valproic acid (Depakote) due to the medication's potential to affect liver function and increase the risk of liver toxicity. While kidney function tests (choice B), thyroid function tests (choice C), and complete blood count (choice D) are important in various clinical scenarios, the priority when administering valproic acid is to monitor liver function to prevent adverse effects associated with this medication.