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. Administer disulfiram immediately.
- B. Place in a side-lying position with the head of the bed elevated.
- C. Give lorazepam PRN for signs of withdrawal.
- D. Provide thiamine and folate supplements as prescribed.
Correct Answer: B
Rationale: Placing the client in a side-lying position with the head elevated prevents aspiration and maintains airway patency, critical for a client with altered consciousness.
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The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?
- A. A young woman who suddenly goes blind with no indication of organic pathology.
- B. An older adult who continuously complains of a headache and back pain.
- C. An adolescent who becomes extremely anxious about going outside.
- D. A middle-aged man who is complaining of shortness of breath and is diaphoretic.
Correct Answer: A
Rationale: Sudden blindness with no organic pathology is indicative of a conversion disorder, involving neurological symptoms without a neurological basis.
The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?
- A. The voices you are hearing are not real.
- B. Let's talk about the next time this happens.
- C. You need to be calm and focus on something else.
- D. You appear to be speaking with someone.
- E. None.
- F. None.
Correct Answer: D
Rationale: Acknowledging that the client appears to be speaking with someone validates their experience without confirming the reality of the voices, encouraging further communication.
The nurse is teaching a group of adolescents about assertive communication. Two of the adolescents are seated at a round table and another is sitting on a small sofa nearby. To facilitate group interaction, which intervention is best for the nurse to implement?
- A. Allow the adolescents to sit wherever they wish as long as they participate.
- B. Suggest that they all sit together to increase interaction.
- C. Ask the adolescent sitting on the couch to join the group at the table.
- D. Determine which adolescents would like to participate in the discussion.
Correct Answer: C
Rationale: Asking the adolescent on the couch to join the table promotes inclusivity and equal participation, enhancing group interaction.
A client is admitted to an inpatient psychiatric unit, and the antipsychotic medication clozapine is prescribed. Which intervention should the nurse include in this client's plan of care?
- A. Inform unlicensed assistive personnel (UAP) that the client will likely complain of a sore throat and fever.
- B. Place the client in protective isolation for the first two weeks of treatment with this medication.
- C. Offer this medication to the client with food to decrease the possibility of gastric upset.
- D. Report findings from the client's weekly white blood cell (WBC) counts to the healthcare provider.
Correct Answer: D
Rationale: Clozapine is associated with the risk of agranulocytosis, so regular monitoring of WBC counts and reporting findings to the healthcare provider is essential.
A client with opioid dependence makes a statement to the nurse about desiring to lead a healthier lifestyle by making changes in the next 2 weeks. How should the nurse respond?
- A. Support the client to list small behavioral changes needed.
- B. Explain the specific skills needed to prevent a relapse.
- C. Provide teaching on the symptoms of substance use dependence.
- D. Advise the client to reschedule until committing to recovery.
Correct Answer: A
Rationale: Supporting the client to list small behavioral changes is a person-centered approach that promotes achievable progress toward a healthier lifestyle.