Nokea
A client is taking chlordiazepoxide (Librium) for generalized anxiety disorder symptoms. In which situation should a nurse recognize that this client is at greatest risk for drug overdose?
- A. When the client has a knowledge deficit related to the effects of the drug
- B. When the client combines the drug with alcohol
- C. When the client takes the drug on an empty stomach
- D. When the client fails to follow dietary restrictions
Correct Answer: B
Rationale: The correct answer is B: When the client combines the drug with alcohol. Combining chlordiazepoxide with alcohol can potentiate the central nervous system depression effects, leading to respiratory depression, sedation, and potential overdose. Alcohol can enhance the sedative effects of chlordiazepoxide, increasing the risk of overdose. A, C, and D are incorrect because a knowledge deficit, taking the drug on an empty stomach, or failing to follow dietary restrictions are not directly related to increasing the risk of drug overdose in this specific scenario.
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An unemployed college graduate is experiencing severe anxiety over not finding a teaching position and has difficulty with independent problem-solving. During a routine physical examination, the graduate confides in the clinic nurse. Which is the most appropriate nursing intervention?
- A. Encourage the student to use the alternative coping mechanism of relaxation exercises.
- B. Complete the problem-solving process for the client.
- C. Work through the problem-solving process with the client.
- D. Encourage the client to keep a journal.
Correct Answer: C
Rationale: The correct answer is C: Work through the problem-solving process with the client. This option promotes empowerment and autonomy by guiding the client to develop their problem-solving skills. It allows the nurse to offer support and guidance without taking over the process entirely, fostering independence and self-efficacy. Encouraging the client to actively participate in finding solutions can help build confidence and improve their ability to handle similar situations in the future.
Explanation for other choices:
A: Encouraging relaxation exercises can be helpful for managing anxiety, but it does not directly address the underlying issue of developing problem-solving skills.
B: Completing the problem-solving process for the client does not empower the client to learn how to address similar challenges independently.
D: Keeping a journal can be a helpful tool for self-reflection and managing emotions, but it does not specifically address the client's difficulty with independent problem-solving.
An involuntarily committed client is verbally abusive to the staff and repeatedly threatening to sue. The client records the full names and phone numbers of the staff. Which nursing action is most appropriate to decrease the possibility of a lawsuit?
- A. Verbally redirect the client, and then limit one-on-one interaction.
- B. Involve the hospitals security division as soon as possible.
- C. Notify the client that documenting personal staff information is against hospital policy.
- D. Continue professional attempts to establish a positive working relationship with the client.
Correct Answer: C
Rationale: The most appropriate nursing action is to choose option C: Notify the client that documenting personal staff information is against hospital policy. This response is effective in addressing the situation because it clearly communicates boundaries to the client and informs them of the hospital's policy. By doing so, the client is made aware that their behavior is not acceptable and that there are consequences for violating the policy. This action also helps to protect the staff members' privacy and security.
Option A: Verbally redirect the client and then limit one-on-one interaction, may not effectively address the issue of the client recording personal staff information. Option B: Involve the hospital's security division as soon as possible, is a more drastic measure that may escalate the situation unnecessarily. Option D: Continue professional attempts to establish a positive working relationship with the client, is not appropriate in this scenario as the client's behavior is threatening and abusive.
A client diagnosed with post-traumatic stress disorder is admitted to an inpatient psychiatric unit for evaluation and medication stabilization. Which therapeutic communication technique used by the nurse is an example of a broad opening?
- A. What occurred prior to the rape, and when did you go to the emergency department?
- B. What would you like to talk about?
- C. I notice you seem uncomfortable discussing this.
- D. How can we help you feel safe during your stay here?
Correct Answer: B
Rationale: The correct answer is B because it allows the client to lead the conversation and express their concerns freely. By asking, "What would you like to talk about?" the nurse demonstrates empathy, respect, and openness to the client's needs, facilitating a client-centered approach. Choice A is specific and may not be what the client wants to discuss. Choice C reflects the nurse's observation rather than encouraging the client to share. Choice D focuses on the nurse's agenda rather than the client's preferences.
Which therapeutic communication technique is being used in this nurseclient interaction? Client: When I get angry, I get into a fistfight with my wife or I take it out on the kids. Nurse: I notice that you are smiling as you talk about this physical violence.
- A. Encouraging comparison
- B. Exploring
- C. Formulating a plan of action
- D. Making observations
Correct Answer: D
Rationale: The correct answer is D, Making observations. The nurse is objectively stating what they notice, which is the client smiling while discussing physical violence. This technique helps bring awareness to the client's behavior without judgment. Encouraging comparison (A) involves asking the client to compare similarities and differences, which is not present in this interaction. Exploring (B) involves delving deeper into the client's thoughts and feelings, which is not demonstrated here. Formulating a plan of action (C) involves working with the client to create a plan for addressing issues, which is not the focus of the nurse's statement.
When under stress, a client routinely uses an excessive amount of alcohol. Finding her drunk, her husband yells at her about the chronic alcohol abuse. Which reaction should the nurse recognize as the use of the defense mechanism of denial?
- A. Hiding liquor bottles in a closet
- B. Yelling at their son for slouching in his chair
- C. Burning dinner on purpose
- D. Saying to the spouse, I dont drink too much!
Correct Answer: D
Rationale: The correct answer is D because the client is using denial as a defense mechanism to cope with the stress of being confronted about her alcohol abuse. By saying "I don't drink too much," she is refusing to acknowledge the reality of her excessive alcohol consumption. This denial allows her to avoid facing the uncomfortable truth and the need for change.
A: Hiding liquor bottles in a closet is an example of a defense mechanism called displacement, not denial.
B: Yelling at their son for slouching in his chair is an example of a defense mechanism called projection, not denial.
C: Burning dinner on purpose is an example of a defense mechanism called passive-aggression, not denial.