Nokea
If the client's drug screen is positive for cocaine, it is most appropriate for the nurse to advise a staff person to monitor the client closely for which finding?
- A. Cardiac arrhythmias
- B. Depressed respirations
- C. Low heart rate
- D. Elevated blood glucose level
Correct Answer: A
Rationale: Cocaine's stimulant effects increase the risk of cardiac arrhythmias, a potentially life-threatening complication requiring close monitoring.
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The nurse is interacting with the client who abuses methamphetamine. The client states “I don’t plan to quit meth. I can work for days when I’m high.” Which is the best response by the nurse?
- A. “You’ll exhaust yourself working days when you’re high.”
- B. “You can’t see the real problem yet because you’re in denial.”
- C. “You say you don’t plan to quit. Do you think using drugs helps you?”
- D. “Good point. You probably do work long hours while you are on meth.”
Correct Answer: C
Rationale: Restating neutrally (C) encourages reexamination. Directives (A) labeling denial (B) or agreeing (D) are less effective.
The client has been placed in involuntary seclusion. Which assessment observation best indicates to the nurse the client’s readiness to leave involuntary seclusion?
- A. The client calmly stating “I have control over my anger now.”
- B. BP is 110/64 mm Hg; P is 82 bpm and regular; R is 16 bpm and regular.
- C. Client is observed sitting in seclusion room doorway asking staff for a drink.
- D. Medical record states “Seclusion of 45 minutes resulted in improved control.”
Correct Answer: C
Rationale: Sitting in the doorway and requesting a drink (C) shows tolerance to stimuli. Statements (A) vital signs (B) and records (D) are less definitive than observed behavior.
The client states “I go out just about every weekend and drink pretty heavily with my friends. Does that mean I’m dependent on alcohol?” Which is the best response by the nurse?
- A. “You’re not dependent on alcohol if you never drink to the point of intoxication.”
- B. “It sounds like you feel guilty about how much you drink. Tell me more about this.”
- C. “With dependence you have a strong need to drink and feel uncomfortable if you don’t.”
- D. “You could be dependent. Consuming alcohol pretty heavily every weekend is excessive.”
Correct Answer: C
Rationale: Dependence involves a compulsive need causing distress if unmet (C). Intoxication (A) or frequency (D) don’t define it and guilt (B) is irrelevant.
The client is receiving clonidine to relieve selected symptoms of opioid withdrawal. Which assessment is most important for the nurse to complete before administering clonidine?
- A. Check for presence of dilated pupils
- B. Investigate recent nausea or vomiting
- C. Test for abnormally heightened reflexes
- D. Verify that the blood pressure is not low
Correct Answer: D
Rationale: Clonidine requires BP check (D) to avoid hypotension. Dilated pupils (A) nausea (B) and reflexes (C) don’t contraindicate it.
What nursing approach is most beneficial for helping the nursing assistant at this time?
- A. Sending the nursing assistant home for the rest of the shift
- B. Terminating the nursing assistant from this type of work
- C. Allowing the nursing assistant to express feelings
- D. Asking the nursing assistant to help with postmortem care
Correct Answer: C
Rationale: Allowing expression of feelings helps the assistant process grief, supporting emotional well-being after a distressing event.