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As a general guide for emergency management of acute alcohol intoxication, it is important for the nurse initially to obtain data regarding which of the following?
- A. What and how much the client drinks, according to family and friends
- B. The blood alcohol level of the client
- C. The blood pressure level of the client
- D. The blood glucose level of the client
Correct Answer: B
Rationale: Blood alcohol levels are generally obtained to determine the level of intoxication. The amount of alcohol consumed determines how much medication the client needs for detoxification and treatment. Reports of alcohol consumption are notoriously inaccurate.
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On admission of this patient, which of the following should be assessed first?
- A. blood pressure
- B. skin breakdown
- C. serum potassium
- D. urine output
Correct Answer: A
Rationale: Blood pressure assessment is critical in pulmonary edema to guide treatment and assess cardiovascular status.
The nurse is caring for an adult who has ulcerative colitis. When planning care, the nurse knows that which nursing diagnosis is of highest priority?
- A. Deficient fluid volume
- B. Disturbed body image
- C. Risk for impaired skin integrity
- D. Risk for ineffective health maintenance
Correct Answer: A
Rationale: Ulcerative colitis causes diarrhea, leading to fluid loss and dehydration, making deficient fluid volume the highest priority to prevent systemic complications like hypovolemia.
A nurse is providing care for an elderly patient with dementia. Which of the following interventions is most appropriate?
- A. Encourage the patient to make complex decisions
- B. Provide a structured routine
- C. Limit social interactions
- D. Avoid physical activity
Correct Answer: B
Rationale: A structured routine reduces confusion and promotes safety in dementia. Complex decisions overwhelm, social interactions benefit, and activity supports health.
An adult is scheduled for a magnetic resonance imaging (MRI) exam today. Which finding must be reported immediately?
- A. The client has pins in her toes.
- B. The client usually wears a necklace.
- C. The client used to work in the x-ray department.
- D. The client has a pacemaker.
Correct Answer: D
Rationale: Pacemakers are contraindicated for MRI due to magnetic field interference, risking device malfunction, requiring immediate reporting, unlike pins, necklaces, or prior x-ray work.
A client is sent to the psychiatric unit for forensic evaluation after he is accused of arson. His tentative diagnosis is antisocial personality disorder. In reviewing the client's record, the nurse could expect to find:
- A. A history of consistent employment
- B. A below-average intelligence
- C. A history of cruelty to animals
- D. An expression of remorse for his actions
Correct Answer: C
Rationale: Antisocial personality disorder is associated with a history of cruelty to animals , reflecting disregard for others. Consistent employment and remorse are unlikely. Intelligence is typically average or above.