Nokea
A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?
- A. Place in a side-lying position with head of bed elevated.
- B. Administer disulfiram (Antabuse) immediately
- C. Give lorazepam (Ativan) PRN for signs of withdrawal.
- D. Provide thiamine and folate supplements as prescribed.
Correct Answer: A
Rationale: The correct answer is A: Place in a side-lying position with head of bed elevated. This is the priority intervention because the client is difficult to arouse, indicating potential risk for airway compromise and aspiration due to the head injury and elevated BAL. Placing the client in a side-lying position with the head of the bed elevated helps prevent aspiration and promotes optimal airway management. Administering disulfiram (choice B) is not indicated as the priority intervention in this acute situation. Giving lorazepam (choice C) for signs of withdrawal may further depress the client's level of consciousness and is not the priority at this time. Providing thiamine and folate supplements (choice D) is important for alcohol-related deficiencies but does not address the immediate risk of airway compromise.
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Which factors tend to increase the difficulty of diagnosing young children who demonstrate behaviors associated with mental illness? Select all that apply.
- A. Limited language skills
- B. Level of cognitive development
- C. Level of emotional development
- D. Parental denial that a problem exists
Correct Answer: B
Rationale: The correct answer is B: Level of cognitive development. Diagnosing mental illness in young children is challenging due to their limited ability to express their thoughts and emotions. Their cognitive development affects their capacity to understand and communicate symptoms, making it harder to assess their mental health accurately. Limited language skills (A) and emotional development (C) can also contribute to the difficulty of diagnosis, but cognitive development plays a more significant role. Parental denial (D) may hinder seeking help but is not a factor that directly impacts the diagnostic process in the child.
James is a 42-year-old patient with schizophrenia. He approaches you as you arrive for day shift and anxiously reports, “Last night, demons came to my room and tried to rape me.†Which response would be most therapeutic?
- A. There are no such things as demons. What you saw were hallucinations.
- B. It is not possible for anyone to enter your room at night. You are safe here.
- C. You seem very upset. Please tell me more about what you experienced last night.
- D. That must have been very frightening, but we’ll check on you at night and you’ll be safe.
Correct Answer: C
Rationale: The correct answer is C because it demonstrates empathy and active listening. By acknowledging James's feelings and inviting him to share more about his experience, the response validates his emotions and fosters trust. This approach helps build a therapeutic relationship and allows for a deeper exploration of his hallucinations. Options A and B invalidate James's experience and may increase his distress. Option D offers reassurance but lacks the immediate emotional support James needs.
Which activity is most appropriate for a child with ADHD?
- A. Reading an adventure novel
- B. Monopoly
- C. Checkers
- D. Tennis
Correct Answer: D
Rationale: The most appropriate activity for a child with ADHD is D: Tennis. Tennis involves physical activity, which can help release excess energy and improve focus. It also requires quick thinking, coordination, and concentration, which can benefit children with ADHD. Reading an adventure novel (A) may be too sedentary, Monopoly (B) and Checkers (C) are more sedentary and may not provide enough physical activity or engagement to help manage ADHD symptoms effectively. Tennis provides a balance of physical activity and mental engagement, making it the most suitable choice.
A female patient diagnosed with schizophrenia has been prescribed a first-generation antipsychotic medication. What information should the nurse provide to the patient regarding her signs and symptoms?
- A. Her memory problems will likely decrease.
- B. Depressive episodes should be less severe.
- C. She will probably enjoy social interactions more.
- D. She should experience a reduction in hallucinations.
Correct Answer: D
Rationale: The correct answer is D: She should experience a reduction in hallucinations. First-generation antipsychotic medications are primarily used to target positive symptoms of schizophrenia, such as hallucinations. These medications work by blocking dopamine receptors in the brain, which can help reduce hallucinations. Providing this information to the patient is crucial for managing expectations and understanding the potential benefits of the prescribed medication.
Choices A, B, and C are incorrect because first-generation antipsychotics do not specifically address memory problems, depressive episodes, or social interactions. While some side effects of the medication may impact these areas, the primary focus is on reducing hallucinations and other positive symptoms of schizophrenia. It is important for the nurse to provide accurate information to the patient to ensure effective treatment and management of their condition.
During an admission assessment and interview, which channels of information communication should the nurse be monitoring? Select all that apply.
- A. Auditory
- B. Visual
- C. Written
- D. Tactile
Correct Answer: A
Rationale: The correct answer is A: Auditory. During an admission assessment and interview, monitoring auditory communication channels is crucial for gathering information through spoken words, tone, and non-verbal cues like sighs or hesitations. This helps the nurse assess the patient's mental state, emotions, and communication effectiveness. Visual (B), written (C), and tactile (D) channels are not typically monitored during a standard interview, as they may not provide relevant information for the assessment process. Visual cues like body language can be important but are not as essential as auditory cues in this context. Written communication is not typically used in a face-to-face interview, and tactile communication is usually unnecessary unless specific procedures are being performed.