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Which explanation by the nurse is most accurate?
- A. The client was frightened of them as a child.
- B. The client is frightened of being injured.
- C. The client associates the sound of the fireworks with gunfire.
- D. The client is afraid it will trigger memories.
Correct Answer: C
Rationale: The veteran's startled reaction likely stems from associating fireworks with gunfire, a common PTSD trigger due to past combat exposure.
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Which information is most appropriate for the nurse to tell the client about taking alprazolam (Xanax)?
- A. Avoid consuming alcohol while taking this drug.
- B. Take the medication with a full meal.
- C. This drug can cause insomnia in some people.
- D. A blood test will be required periodically.
Correct Answer: A
Rationale: Alcohol potentiates alprazolam's sedative effects, increasing the risk of respiratory depression and overdose, making this a critical instruction.
The nurse is preparing to care for the newly hospitalized client diagnosed with Korsakoff’s psychosis from alcohol abuse. Which intervention should the nurse plan to implement?
- A. Administer thiamine intravenously.
- B. Give octreotide acetate intravenously
- C. Apply soft wrist restraints for safety.
- D. Start oxygen at 2 L/min per nasal cannula.
Correct Answer: A
Rationale: Thiamine (A) treats confusion in Korsakoff’s due to deficiency. Octreotide (B) is for varices restraints (C) are not first-line and oxygen (D) is irrelevant.
彼此The client who abuses marijuana reports liking the drug for its perceived effects. Which experiences if reported by the client should the nurse attribute to marijuana use? Select all that apply.
- A. Euphoria
- B. Increased energy
- C. Sexual enhancement
- D. Appetite suppression
- E. Improved fine-muscle coordination
Correct Answer: A, C
Rationale: Marijuana causes euphoria (A) and enhances sexual experience (C). It causes lethargy (not energy B) increased appetite (not suppression D) and tremors (not coordination E).
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.
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.