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A client with a history of alcohol use disorder is admitted to the hospital. Which assessment finding would indicate early alcohol withdrawal?
- A. Bradycardia
- B. Hypotension
- C. Diaphoresis
- D. Hypothermia
Correct Answer: C
Rationale: In a client experiencing early alcohol withdrawal, one of the key assessment findings is diaphoresis (excessive sweating). This is due to autonomic hyperactivity commonly seen during this phase, along with other signs like tremors and tachycardia. Bradycardia (slow heart rate), hypotension (low blood pressure), and hypothermia (low body temperature) are not typically associated with early alcohol withdrawal, making them incorrect choices.
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When evaluating a client's progress in psychotherapy, which outcome is appropriate for the client?
- A. The client will identify triggers for anxiety.
- B. The client will develop coping strategies.
- C. The client will decrease avoidance behaviors.
- D. The client will express feelings of anger.
Correct Answer: A
Rationale: In psychotherapy, identifying triggers for anxiety is a crucial step towards understanding and managing one's anxiety symptoms. By recognizing these triggers, clients can work on developing coping strategies and addressing the root cause of their anxiety, leading to improved mental health outcomes. Decreasing avoidance behaviors and expressing feelings of anger are also important aspects of therapy. However, identifying triggers for anxiety is a more specific and foundational goal in addressing anxiety disorders, making it the most appropriate outcome to evaluate a client's progress in psychotherapy.
A client with obsessive-compulsive disorder (OCD) spends several hours each day washing her hands. Which intervention should the nurse implement?
- A. Encourage the client to wash her hands less frequently.
- B. Set a time limit for hand washing.
- C. Teach the client relaxation techniques.
- D. Discourage the client from washing her hands.
Correct Answer: B
Rationale: Setting a time limit for hand washing is an appropriate intervention for a client with OCD who spends excessive time on this compulsive behavior. By setting a time limit, the nurse can help the client gradually reduce the compulsive behavior, promoting a more manageable approach to hand washing without completely discouraging it. Encouraging the client to wash her hands less frequently (Choice A) may not address the root of the issue and could lead to increased anxiety. Teaching relaxation techniques (Choice C) may be helpful for overall anxiety management but may not directly address the excessive hand washing behavior. Discouraging the client from washing her hands (Choice D) may increase anxiety and resistance, making it a less effective intervention.
A client is being treated for obsessive-compulsive disorder (OCD). Which intervention should be included in the care plan?
- A. Discourage the client from performing rituals.
- B. Allow the client to perform rituals in the early stages of treatment.
- C. Encourage the client to focus on their compulsions.
- D. Isolate the client to prevent performance of rituals.
Correct Answer: B
Rationale: Allowing the client to perform rituals in the early stages of treatment is a common therapeutic approach for obsessive-compulsive disorder (OCD). Allowing the client to engage in rituals can help reduce anxiety by providing temporary relief. It is a part of exposure therapy, where the individual is gradually exposed to anxiety-provoking situations. As treatment progresses, the focus shifts to gradually reducing the frequency and intensity of rituals through interventions like exposure and response prevention therapy. Discouraging the client from performing rituals (Choice A) is not recommended as it may increase anxiety and resistance to treatment. Encouraging the client to focus on their compulsions (Choice C) may reinforce the behavior rather than helping to decrease it. Isolating the client (Choice D) is not therapeutic and can lead to feelings of abandonment and worsen symptoms.
A client has been prescribed fluoxetine (Prozac). What information should the nurse include in discharge teaching?
- A. Take the medication with food to avoid stomach upset.
- B. Avoid drinking alcohol while taking this medication.
- C. Take the medication only when feeling depressed.
- D. Report any unusual side effects to the healthcare provider.
Correct Answer: B
Rationale: The correct answer is to advise the client to avoid drinking alcohol while taking fluoxetine (Prozac) due to potential interactions. Alcohol consumption can increase the risk of certain side effects and may reduce the effectiveness of the medication. Choice A is incorrect because fluoxetine can be taken with or without food. Choice C is incorrect as fluoxetine is usually taken daily regardless of the client's mood. Choice D is not the priority teaching point; while reporting side effects is important, avoiding alcohol is critical due to the potential interactions.
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.