Nokea
A client is admitted for a drug overdose with a Barbiturate. Which is the priority nursing action when planning care for this client?
- A. Check the client's belongings for additional drugs.
- B. Pad the side rails of the bed because seizures are likely.
- C. Prepare a dose of ipecac, an emetic.
- D. Monitor respiratory function.
Correct Answer: D
Rationale: Barbiturate overdose depresses respiratory function, making monitoring the priority to ensure safety, over checking belongings, padding rails, or using ipecac.
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The client asks the nurse, 'What will happen if I drink while taking Antabuse?' What should be the nurse's reply?
- A. You will not want to drink while taking Antabuse, it reduces the cravings.
- B. You will not get any effect from the alcohol you drink.
- C. Antabuse will reverse the effects of alcohol.
- D. You will experience a severe reaction, including a throbbing headache and vomiting.
Correct Answer: D
Rationale: Drinking on Antabuse causes severe symptoms like headache and vomiting, not reduced cravings, no alcohol effect, or reversal of alcohol effects.
A nurse suspects a coworker is signing out narcotics for clients and is using them herself. Which action should be taken by the nurse who has these suspicions?
- A. Ignore suspicions and leave it to the supervisor to intervene.
- B. Report the observations to the supervisor.
- C. Follow behind the coworker to ensure client comfort and safety.
- D. Confront the coworker about suspicions.
Correct Answer: B
Rationale: Reporting to a supervisor fulfills ethical and legal responsibilities, ensuring client safety, unlike ignoring, following, or confronting directly.
The wife of a client who is alcoholic asks the nurse how to respond to him in a helpful way when he is disruptive in family life. Which is the nurse's best response?
- A. Help him avoid embarrassment by supporting him when he makes excuses for failing to meet obligations.
- B. Include him in family outings even when he is drinking.
- C. Search the house regularly for alcohol.
- D. Try to maintain a normal home environment for yourself and the children.
Correct Answer: D
Rationale: Maintaining a normal home environment breaks codependency, unlike enabling excuses, including him while drinking, or searching for alcohol.
A client reports drinking one to two drinks when drinking behavior first began. Now the client reports drinking at least six drinks with every episode in order to have a good time. Which term would best describe this phenomenon?
- A. Dependence
- B. Intoxication
- C. Tolerance
- D. Withdrawal
Correct Answer: C
Rationale: Tolerance describes needing more alcohol to achieve the same effect, unlike intoxication (maladaptive behavior), withdrawal (symptoms upon cessation), or dependence (addiction with multiple symptoms).
The nurse is working in an intensive care unit and observes that some clients do not respond to injections of diazepam (Valium) when the injections are given by a particular nurse. This nurse returns from lunch exhibiting slurred speech and euphoria. Which is the best action for the nurse to take?
- A. Ask other nurses if they have noticed anything unusual.
- B. Call the manager and report the observations.
- C. Observe the nurse as injections are prepared and administered.
- D. Tell the nurse, 'I know you've been stealing Valium.'
Correct Answer: B
Rationale: Reporting to the manager addresses suspected diversion and ensures client safety, unlike asking others, observing further, or confronting directly.