Nokea
A client is experiencing alcohol withdrawal. Which symptom should the nurse identify as a priority to address?
- A. Tremors
- B. Nausea and vomiting
- C. Increased blood pressure
- D. Insomnia
Correct Answer: C
Rationale: During alcohol withdrawal, increased blood pressure is a critical symptom that requires immediate attention. Elevated blood pressure can lead to serious complications such as cardiovascular events or stroke. Monitoring and managing blood pressure in clients experiencing alcohol withdrawal is crucial to prevent adverse outcomes. Tremors, nausea and vomiting, and insomnia are common symptoms of alcohol withdrawal, but they are not as immediately life-threatening as increased blood pressure. Therefore, addressing increased blood pressure takes precedence in the management of a client experiencing alcohol withdrawal.
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A client has been diagnosed with depersonalization/derealization disorder. Which of the following behaviors should the nurse expect?
- A. Feelings of detachment from one's body
- B. Fear of gaining weight
- C. Paralysis of a limb
- D. Episodes of hypomania
Correct Answer: A
Rationale: Depersonalization/derealization disorder is characterized by feelings of detachment from one's body or surroundings. Individuals with this disorder may feel like they are observing themselves from outside their body or that the world around them is unreal. Therefore, the nurse should expect behaviors such as feelings of detachment from one's body (A). Fear of gaining weight (B) is more indicative of an eating disorder, paralysis of a limb (C) could be related to neurological issues, and episodes of hypomania (D) are associated with mood disorders like bipolar disorder, but not specifically with depersonalization/derealization disorder.
A client experiencing a manic episode is talking rapidly and jumping from one topic to another. Which term describes this symptom?
- A. Circumstantiality
- B. Flight of ideas
- C. Tangentiality
- D. Perseveration
Correct Answer: B
Rationale: In a manic episode, 'Flight of ideas' is characterized by rapid speech, where the individual moves quickly between topics without a clear connection. This symptom reflects the racing thoughts and impulsivity often seen in manic episodes. Circumstantiality refers to unnecessary detail and delay in getting to the point, tangentiality involves going off on a tangent or unrelated topics, and perseveration is the persistent repetition of a response or behavior. Therefore, 'Flight of ideas' best describes the symptom of rapidly changing topics during a manic episode.
A client is prescribed diazepam (Valium) for anxiety. Which statement by the client indicates a need for further teaching?
- A. I can drink alcohol while taking this medication.
- B. I should avoid drinking alcohol while taking this medication.
- C. I should take this medication only when I feel anxious.
- D. I can stop taking this medication when I feel better.
Correct Answer: A
Rationale: The correct answer is A because clients should avoid alcohol while taking diazepam (Valium) due to potential interactions. Alcohol can increase the sedative effects of diazepam, leading to excessive drowsiness or respiratory depression. Choice B is correct as it reflects the need to avoid alcohol. Choice C is incorrect because diazepam is usually taken regularly, not just when feeling anxious. Choice D is incorrect as abruptly stopping diazepam can lead to withdrawal symptoms and should be done gradually under medical supervision.
A client is experiencing panic attacks. Which intervention should the nurse implement to help the client manage anxiety?
- A. Encourage the client to avoid situations that trigger anxiety.
- B. Encourage the client to practice deep breathing exercises.
- C. Encourage the client to take anti-anxiety medication as prescribed.
- D. Encourage the client to engage in regular physical activity.
Correct Answer: B
Rationale: During panic attacks, deep breathing exercises can help the client manage anxiety effectively by promoting relaxation and reducing the intensity of symptoms. Encouraging the client to practice deep breathing can provide a quick and accessible strategy to cope with the immediate distress of a panic attack. Choices A, C, and D are incorrect because avoiding triggering situations may reinforce avoidance behavior, anti-anxiety medication is not the first-line intervention during a panic attack, and engaging in physical activity may not be feasible or effective during an acute episode of panic.
When caring for a client experiencing alcohol withdrawal, which intervention should the nurse implement to prevent complications?
- A. Provide a well-lit environment.
- B. Administer antipsychotic medication as prescribed.
- C. Monitor the client's vital signs closely.
- D. Encourage the client to express their feelings.
Correct Answer: D
Rationale: Encouraging the client to express their feelings is essential during alcohol withdrawal as it can help them cope with the emotional and psychological stress associated with the process. This intervention promotes open communication, allows the client to verbalize their emotions, and may prevent escalating anxiety or agitation, ultimately reducing the risk of complications. Providing a well-lit environment (Choice A) is not directly related to preventing complications of alcohol withdrawal. Administering antipsychotic medication (Choice B) is not the standard treatment for alcohol withdrawal; medications such as benzodiazepines are more commonly used. While monitoring vital signs (Choice C) is important, encouraging the client to express their feelings (Choice D) directly addresses emotional well-being, which is crucial during this vulnerable time.