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A nurse in a rehabilitation center is planning care for a newly admitted client who has a history of alcohol use disorder. Which of the following client goals is the highest priority?
- A. The client will acknowledge alcohol dependence and need for treatment.
- B. The client will rebuild damaged interpersonal relationships.
- C. The client will implement alternative strategies for managing anxiety.
- D. The client's withdrawal from alcohol will be managed without complications.
Correct Answer: D
Rationale: The correct answer is D because managing alcohol withdrawal without complications is the highest priority to ensure the client's safety and well-being. Withdrawal from alcohol can lead to life-threatening complications such as seizures and delirium tremens. Addressing this goal first is crucial for stabilizing the client physically.
Choice A is important but not the highest priority as immediate physical safety takes precedence. Choices B and C are important for overall recovery but do not address the immediate risk of withdrawal complications.
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A nurse is caring for a client who is terminally ill and exhibiting signs of impending death. The client's medical record states that the client is a practicing Roman Catholic. Which of the following nursing actions is appropriate?
- A. Offer to make arrangements for the Sacrament of the Sick.
- B. Prepare to stay with the client's body after death until family arrives.
- C. Arrange for a member of the client's faith to bathe the body after death.
- D. Post a sign on the client's door stating, “No Talking.”
Correct Answer: A
Rationale: The correct answer is A: Offer to make arrangements for the Sacrament of the Sick. This is appropriate because the client is a practicing Roman Catholic, and the Sacrament of the Sick is a sacrament in the Catholic faith administered to the sick or dying. Offering to arrange for this sacrament shows respect for the client's religious beliefs and provides spiritual comfort.
Choice B is incorrect because staying with the client's body after death is not necessarily a religious practice and may not align with the client's beliefs. Choice C is incorrect as it assumes the client's faith requires a specific individual to bathe the body, which may not be the case for all Roman Catholics. Choice D is incorrect as it is not relevant to the client's religious needs and may hinder communication during this sensitive time.
A nurse is providing teaching to a client who has alcohol use disorder about Alcoholics Anonymous (AA). Which of the following client statements indicates an understanding of the program's basic concepts?
- A. "I am responsible for my alcoholism."
- B. "I need to identify things that cause me to be an alcoholic."
- C. "I am powerless against my addiction to alcohol."
- D. "I need to see a counselor who will be responsible for my recovery."
Correct Answer: C
Rationale: AA is based on the principle of acknowledging powerlessness over addiction and seeking support.
A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following characteristics are expected findings of OCD? (Select all that apply.)
- A. Difficulty relaxing
- B. Irrational fear of certain objects
- C. Rule-conscious behavior
- D. Unaware of compulsions
- E. Perfectionist behavior
Correct Answer: A, B, C, E
Rationale: Correct Answer: A, B, C, E
Rationale:
A: Difficulty relaxing is an expected finding in OCD due to persistent intrusive thoughts causing anxiety and tension.
B: Irrational fear of certain objects is common in OCD, leading to compulsive behaviors to reduce anxiety.
C: Rule-conscious behavior is a characteristic of OCD where individuals feel compelled to follow specific routines or rules.
E: Perfectionist behavior is a common trait in OCD as individuals strive for perfection to alleviate anxiety.
Incorrect Choices:
D: Individuals with OCD are usually aware of their compulsions, distinguishing them from other disorders.
F, G: No additional choices provided.
Summary:
The correct answers (A, B, C, E) align with the typical symptoms of OCD, including anxiety, compulsions, rule-following, and perfectionism. The incorrect choices (D, F, G) do not accurately reflect the expected findings in OCD.
Which action is most therapeutic for a client with panic-level anxiety?
- A. Suggest the client rest in bed
- B. Remain with the client
- C. Medicate the client with a sedative
- D. Have the client join a therapy group
Correct Answer: B
Rationale: The correct answer is B: Remain with the client. This is the most therapeutic action because it provides immediate reassurance and support to the client, helping to reduce feelings of isolation and fear during a panic attack. By staying with the client, you can offer comfort and help them feel safe and supported.
Choice A is incorrect as suggesting the client rest in bed may not address their immediate needs during a panic attack. Choice C, medicating the client with a sedative, may provide short-term relief but does not address the underlying causes of the anxiety. Choice D, having the client join a therapy group, is not suitable during a panic attack as the client needs immediate support and intervention.
A nurse is caring for a client who has bipolar disorder and a new prescription for valproate. Which of the following instructions should the nurse give the client about the use of this medication?
- A. Thyroid function tests should be performed every 6 months.
- B. A pretreatment electroencephalogram (EEG) will be done.
- C. Liver function tests should be monitored.
- D. High serum sodium levels can cause toxic levels of valproate.
Correct Answer: C
Rationale: Valproate is metabolized in the liver, requiring regular liver function monitoring.