Nokea
A client who is an alcoholic receives a prescription for disulfiram 500 mg by mouth (PO) daily. Which instruction should the nurse provide to this client?
- A. Take the medication at bedtime and avoid consuming any more than one ounce of alcohol
- B. Take the medication with at least 8 ounces (240 mL) of water and limit alcohol consumption while taking this medication
- C. Begin taking the medication immediately and take it daily, regardless of whether or not you drink alcohol
- D. Take the medication each morning beginning 48 hours after your last drink of alcohol
Correct Answer: D
Rationale: Disulfiram must be started at least 48 hours after the last alcohol intake to prevent severe reactions, and alcohol must be completely avoided. Options A and B incorrectly suggest limited alcohol is safe. Option C risks reactions if alcohol is still in the system.
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The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessment?
- A. The snakes on the wall are going to eat me
- B. The nurse at night is trying to poison me with pills
- C. The voices are telling me to kill the next person I see
- D. The fire is burning my skin away right now
- E. None
- F. None
Correct Answer: B
Rationale: The nurse at night is trying to poison me with pills' confirms a delusion, specifically a paranoid delusion, as it reflects a fixed, false belief not based in reality. The other options describe hallucinations: visual ('snakes'), auditory ('voices'), and tactile ('fire'). Delusions involve false beliefs, while hallucinations involve false sensory perceptions.
The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?
- A. Alert the assigned staff to closely monitor client and intervene as needed to reduce risk of self-mutilation
- B. Provide the client time alone in the client's room to reduce external stimulation and promote relaxation
- C. Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed
- D. Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm
Correct Answer: A
Rationale: Alerting staff to monitor the client closely addresses the immediate risk of self-harm indicated by increased tension and pacing. Time alone may increase risk. Setting expectations is important but not immediate. Room searches are preventive but not the priority during acute distress.
A young female client is admitted to the emergency room because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record as the client's chief complaint?
- A. Client claims that she was forced to participate in sexual intercourse
- B. Client reported that she had sexual relations against her will
- C. Client has been sexually assaulted
- D. Client states, 'My date raped me tonight'
Correct Answer: D
Rationale: Client states, 'My date raped me tonight' is the most accurate and objective, using the client's own words to document the chief complaint without implying doubt ('claims') or minimizing the trauma. 'Sexual assault' is accurate but less specific.
The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?
- A. A middle-aged man who is complaining of shortness of breath and is diaphoretic
- B. A young woman who suddenly goes blind with no indication of organic pathology
- C. An older adult who continuously complains of a headache and back pain
- D. An adolescent who becomes extremely anxious about going outside
Correct Answer: B
Rationale: Sudden blindness with no organic pathology suggests a functional neurological symptom disorder, which falls under conversion disorder. Shortness of breath and diaphoresis may indicate a medical condition or panic attack. Headaches and back pain could have various causes. Anxiety about going outside suggests agoraphobia or another anxiety disorder.
The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?
- A. Stimulation and dilated pupils
- B. Bradycardia and bradypnea
- C. Hallucinations and delusions
- D. Lethargy and depression
Correct Answer: A
Rationale: Cocaine use typically results in stimulation of the central nervous system, leading to increased heart rate, dilated pupils, and heightened alertness. Bradycardia and bradypnea are not typical, as cocaine causes tachycardia and increased respiratory rate. Hallucinations and delusions are more associated with hallucinogens or psychotic disorders. Lethargy and depression occur during the 'crash' phase, not the immediate effects of cocaine use.