Nokea
A client with chronic alcohol dependency is admitted due to a recent relapse. Which findings should the nurse expect this client to exhibit? (Select all that apply)
- A. Decreased prothrombin time and partial thromboplastin levels.
- B. Increased values of serum levels for liver function profile.
- C. Increasingly larger amounts of alcohol are needed to feel drunk.
- D. Periodic indigestion with negative occult blood in stool.
- E. Memory lapses of events that occurred when drinking.
Correct Answer: B,C,D,E
Rationale: Increased liver function profile values, tolerance to alcohol, indigestion, and memory lapses are common in chronic alcohol dependency, reflecting liver damage, tolerance, gastrointestinal issues, and blackouts.
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The nurse is caring for a client who is a refugee from another country and who is experiencing daily episodes of anxiety. The client communicates minimally with the nurse, looking away and appearing distressed. Which intervention is most important for the nurse to do first?
- A. Reinforce personal strengths observed in the client.
- B. Suggest ways to problem solve adapting to the new home.
- C. Help the client know they will not always feel this way.
- D. Inquire respectfully about the events of the departure.
Correct Answer: D
Rationale: Inquiring respectfully about the events of departure is critical to understand potential traumatic experiences contributing to the client's anxiety.
When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client's record should the nurse review?
- A. The healthcare provider's history and physical.
- B. Recent urine drug testing (UDT) results.
- C. Baseline nursing admission assessment.
- D. Abnormal Involuntary Movement Scale (AIMS).
Correct Answer: D
Rationale: The Abnormal Involuntary Movement Scale (AIMS) is specifically designed to assess and document involuntary movements associated with psychotropic medications, making it the most relevant assessment tool for these symptoms.
An adolescent who is a heroin addict is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?
- A. Assess intake and output.
- B. Monitor for wheezing and apnea.
- C. Limit visitors to family members only.
- D. Assign the client to a teen support group.
Correct Answer: B
Rationale: Monitoring for wheezing and apnea is crucial during the first 24 hours of heroin detoxification to ensure respiratory stability, addressing immediate physiological risks.
While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client's tongue is “wormingâ€. The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain?
- A. Usual level of activity and average sleep pattern.
- B. Blood pressure when sitting and standing.
- C. Dentures to determine if they are poorly fitted.
- D. Body weight over the past three months.
Correct Answer: C
Rationale: Assessing the fit of dentures is crucial, as poorly fitted dentures could contribute to speech difficulties and tongue abnormalities observed.
A male client, assessed in the emergency department (ED), has a strong odor of alcohol on his breath. The client denies thoughts of harm to self or others, and the healthcare provider discharges the client. As the client begins to leave, the nurse overhears the client mumble, “Now I'm going to shoot myself.†Which intervention should the nurse implement?
- A. Inquire about the client's support system.
- B. Ask the client to repeat his comment.
- C. Stop the client from leaving the ED.
- D. Record the statement in the client's chart.
Correct Answer: C
Rationale: Stopping the client from leaving the ED is the priority to ensure safety and prevent potential self-harm based on the overheard statement.