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The nurse is talking with a client with alcohol use disorder who has a new prescription for disulfiram. Which of the following information should the nurse include?
- A. Most clients who take this medication do not need to attend therapy or support groups.
- B. Avoid drinking alcohol for 3 days after discontinuing this medication.
- C. Check for alcohol in household items you use regularly, such as mouthwash.
- D. You can expect to experience decreased cravings for alcohol.
Correct Answer: C
Rationale: Disulfiram causes severe adverse reactions when alcohol is consumed, even in small amounts found in products like mouthwash. Clients must avoid all alcohol-containing products to prevent a disulfiram-alcohol reaction, which can include nausea, vomiting, and flushing.
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The nurse is reviewing the medical record for an adolescent client with major depressive disorder. Which of the following findings would be consistent with the condition? Select all that apply.
- A. often sleeps during class or after-school activities
- B. has received disciplinary action at school due to absenteeism and angry outbursts
- C. has unintentionally lost 8 lb (3.6 kg) over the past 3 weeks
- D. abruptly quit playing sports despite receiving previous athletic awards and trophies
- E. voices concern about the appearance of acne on the face
Correct Answer: A,B,C,D
Rationale: Excessive sleep, irritability (outbursts), weight loss, and loss of interest in activities (quitting sports) are hallmarks of depression. Acne concern is typical adolescent behavior, not specific to depression.
The nurse is caring for a bedridden client experiencing fecal incontinence. Which nursing intervention is the highest priority for this client?
- A. Consult with the wound care nurse specialist
- B. Insert a rectal tube to contain the feces
- C. Provide perianal skin care with barrier cream
- D. Use incontinence briefs to protect the skin
Correct Answer: C
Rationale: Perianal skin care with barrier cream prevents skin breakdown, a common complication of fecal incontinence. Wound care consultation follows if breakdown occurs. Rectal tubes risk complications, and briefs may trap moisture, worsening irritation.
The nurse is caring for a client with HIV. The nurse understands that which of the following are true regarding transmission-based precautions? Select all that apply.
- A. Donning an N95 respiratory mask decreases the risk of transmitting HIV
- B. Gown, gloves, and face shield are necessary for every client encounter
- C. Neutropenic precautions are implemented based on laboratory results
- D. The client's urine is a bodily fluid that can transmit HIV
- E. The nurse should perform hand hygiene before and after providing client care
Correct Answer: C,D,E
Rationale: Neutropenic precautions depend on lab results (e.g., low white blood cell count). Urine can transmit HIV if blood is present. Hand hygiene is standard for all encounters. N95 masks are for airborne diseases, not HIV. Full PPE isn't needed unless splashing of bodily fluids is likely.
The nurse understands that during the 'tension building' phase of a violent relationship, when the batterer makes unreasonable demands, the battered victim may experience feelings of
- A. Anger
- B. Helplessness
- C. Calm
- D. Explosiveness
Correct Answer: B
Rationale: Helplessness. Victims feel depressed and helpless despite efforts to please the batterer.
The home care nurse is observing the client's spouse performing a colostomy irrigation. Which action needs correction?
- A. The spouse holds the irrigating solution about 18 inches above the stoma.
- B. The client is sitting on the toilet seat for the irrigation.
- C. The spouse is using 1000 mL of irrigating solution.
- D. The spouse uses petroleum jelly to lubricate the tip of the catheter.
Correct Answer: D
Rationale: Petroleum jelly is not suitable for lubricating colostomy irrigation catheters, as it may degrade materials or harbor bacteria; water-soluble lubricant is preferred. The height, volume, and position are appropriate.