Nokea
A male client with alcohol use disorder is admitted for detoxification. The nurse knows that which symptom is a sign of severe alcohol withdrawal?
- A. Bradycardia
- B. Seizures
- C. Hyperglycemia
- D. Constipation
Correct Answer: B
Rationale: Seizures are a sign of severe alcohol withdrawal and can be life-threatening, requiring immediate medical attention. Bradycardia, hyperglycemia, and constipation are not typically associated with severe alcohol withdrawal. Bradycardia is more commonly seen in opioid withdrawal, hyperglycemia could be due to other reasons like uncontrolled diabetes, and constipation is not a typical symptom of severe alcohol withdrawal.
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A client is admitted to the mental health unit and reports taking extra anti-anxiety medication because, 'I'm so stressed out. I just wanted to go to sleep.' The nurse should plan one-on-one observation of the client based on which statement?
- A. What should I do? Nothing seems to help.
- B. I have been so tired lately and needed to sleep.
- C. I really think that I don't need to be here.
- D. I don't want to talk. Nothing matters anymore.
Correct Answer: D
Rationale: The correct answer is D because expressing feelings of hopelessness or nihilism can be indicators of a deeper, possibly dangerous level of depression. Choice A is incorrect as it indicates seeking help, Choice B suggests fatigue, and Choice C implies denial of needing help, none of which directly signify severe depression warranting one-on-one observation.
An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the LPN/LVN to provide?
- A. You are in the hospital, and I am the nurse caring for you.
- B. It must be difficult for you to control your anxious feelings.
- C. Go to occupational therapy and start a project.
- D. You are not in a war area now; this is the United States.
Correct Answer: A
Rationale: The best response for the LPN/LVN to provide is option A: 'You are in the hospital, and I am the nurse caring for you.' This response is effective as it grounds the client in the present reality while also acknowledging the client's feelings. It shows acceptance of the client's experience without directly challenging the delusional belief, which can help build rapport and trust. Option B focuses on anxiety rather than validating the client's experience or addressing the delusion. Option C suggests an unrelated activity that may not be helpful in this situation. Option D attempts to correct the client's belief, which is not likely to be effective in managing delusional thoughts.
A 52-year-old male client in the intensive care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveal no significant change, and the nurse formulates the diagnosis, 'Confusion related to ICU psychosis.' Which intervention would be best to implement?
- A. Move all machines away from the client's immediate area.
- B. Attempt to allay the client's fears by explaining the etiology of his condition.
- C. Cluster care so that brief periods of rest can be scheduled during the day.
- D. Extend visitation times for family and friends.
Correct Answer: C
Rationale: In critical care environments, stressors can lead to isolation and confusion. Providing the client with scheduled rest periods (C) can help alleviate these symptoms. Moving all machines away (A) is impractical as they are often essential. Explaining the condition (B) may not be effective during acute confusion. Extending visitation times (D) can be overwhelming for the client in the ICU.
A client with schizophrenia is being discharged with a prescription for risperidone (Risperdal). What is the most important instruction for the nurse to provide?
- A. Stop taking the medication if you start feeling better.
- B. Be aware of the potential for weight gain with this medication.
- C. Report any unusual muscle movements immediately.
- D. You can drive as soon as you feel ready.
Correct Answer: C
Rationale: The correct answer is C: "Report any unusual muscle movements immediately." Unusual muscle movements may indicate extrapyramidal symptoms (EPS) or tardive dyskinesia, which are serious side effects of antipsychotic medications like risperidone. It is crucial to address these symptoms promptly to prevent long-term effects. Choice A is incorrect because stopping the medication suddenly can be dangerous and should only be done under medical supervision. Choice B, while important, is not the most critical instruction in this scenario. Choice D is also incorrect as the ability to drive may be affected by the medication and should be discussed with a healthcare provider.
An LPN/LVN is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis is caused by:
- A. Witnessing a murder
- B. The death of a loved one
- C. A fire that destroyed the client's home
- D. A recent rape episode experienced by the client
Correct Answer: B
Rationale: The correct answer is B: 'The death of a loved one.' A situational crisis, like the death of a loved one, can lead to anxiety due to a significant change or loss in the person's life. Choices A, C, and D involve traumatic events, but a situational crisis typically refers to life events that disrupt an individual's normal pattern of living, such as the death of a loved one.