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A nurse in a substance abuse clinic is assessing a client who is prescribed disulfiram (Antabuse). The client states he stopped the medication after developing severe nausea and vomiting. Which of the following does the nurse realize is most likely the cause of the client's symptoms?
- A. The client took an overdose of the medication.
- B. The client demonstrated an allergic response to the medication.
- C. The client experienced a common side effect of the medication.
- D. The client consumed alcohol while taking the medication.
Correct Answer: D
Rationale: The correct answer is D: The client consumed alcohol while taking the medication. Disulfiram is used to deter alcohol consumption by causing unpleasant reactions when alcohol is ingested. The symptoms of severe nausea and vomiting the client experienced are consistent with the disulfiram-alcohol reaction. This reaction occurs when alcohol is consumed while on disulfiram, leading to a buildup of acetaldehyde, causing discomfort.
Choice A: The client taking an overdose of the medication would typically result in different symptoms, such as neurological effects or liver toxicity.
Choice B: An allergic response to disulfiram would likely manifest as skin rash, itching, or difficulty breathing, rather than nausea and vomiting.
Choice C: While nausea and vomiting are common side effects of disulfiram, they are typically milder and occur when alcohol is consumed, not as a standalone symptom.
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A nurse is admitting a client with a history of alcohol use disorder. The nurse is aware that which of the following are potential physical symptoms of alcohol withdrawal? (Select all that apply.)
- A. Seizures
- B. Tachycardia
- C. Hallucinations
- D. Tremors
- E. Hypotension
Correct Answer: A,B,C,D
Rationale: The correct answer is A, B, C, and D. Alcohol withdrawal can lead to seizures due to hyperexcitability of the nervous system. Tachycardia is common as alcohol withdrawal can cause increased heart rate and blood pressure. Hallucinations are possible due to disturbances in brain function. Tremors are a typical symptom of alcohol withdrawal, known as "the shakes." Choices E and F, hypotension and G, are not typically associated with alcohol withdrawal. In summary, the correct symptoms are related to central nervous system hyperactivity, while the incorrect choices are not commonly observed in alcohol withdrawal.
A nurse has received a report on a group of clients. Which of the following client clients should the nurse assess first?
- A. A client who has type 2 diabetes mellitus has a blood glucose level of 120 mg/dL (74 - 106 mg/dL)
- B. A client who has diabetes insipidus has an intake of 1,500 mL and an output of 1,600 mL in 24 hr.
- C. A client who has Graves' disease has a heart rate of 100/min and reports tremors.
- D. A client who has a left-sided stroke reports severe headache and is manifesting confusion.
Correct Answer: D
Rationale: The correct answer is D. A client with a left-sided stroke reporting severe headache and confusion should be assessed first due to the potential risk of worsening neurological status. Headache and confusion could indicate a worsening condition such as hemorrhage or increased intracranial pressure, requiring immediate intervention to prevent further damage. Assessing this client first allows for prompt treatment and prevention of complications. Choices A, B, and C involve clients with chronic conditions or stable vital signs that do not indicate immediate danger. Assessing the client with a left-sided stroke takes priority over these cases due to the acute nature of the symptoms.
Which of the following is a characteristic sign of hyperthyroidism?
- A. Cold intolerance
- B. Fatigue and lethargy
- C. Tremors and nervousness
- D. Weight gain
Correct Answer: C
Rationale: The correct answer is C: Tremors and nervousness. Hyperthyroidism is an overactive thyroid gland leading to an excess of thyroid hormones. Tremors and nervousness are classic symptoms due to the increased metabolic rate. Cold intolerance (A) is a symptom of hypothyroidism, not hyperthyroidism. Fatigue and lethargy (B) are common in hypothyroidism, not hyperthyroidism. Weight gain (D) is also more indicative of hypothyroidism. Therefore, the presence of tremors and nervousness (C) is the characteristic sign of hyperthyroidism.
The nurse is caring for a client diagnosed with severe intellectual disability. Which of the following characteristics should the nurse recognize to be associated with severe intellectual disability?
- A. The client can perform some self-care activities independently.
- B. The client has advanced speech development.
- C. Other than possible coordination problems,the client's psychomotor skills are not affected.
- D. The client communicates wants and needs by "acting out" behaviors.
Correct Answer: D
Rationale: The correct answer is D because individuals with severe intellectual disability often have limited communication skills and may resort to "acting out" behaviors to express their wants and needs. This is a characteristic commonly associated with severe intellectual disability.
A: The client can perform some self-care activities independently - This is unlikely in severe intellectual disability as individuals typically have limitations in self-care abilities.
B: The client has advanced speech development - Individuals with severe intellectual disability often have significant delays in speech development.
C: Other than possible coordination problems, the client's psychomotor skills are not affected - Individuals with severe intellectual disability commonly have deficits in both cognitive and motor skills.
E, F, G: No additional choices provided for analysis.
The nurse is planning care for a child who has intermittent explosive disorder (IED). The nurse should identify which of the following goals are appropriate for this client? (Select All that Apply.)
- A. The child will demonstrate effective problem-solving skills.
- B. The child will acknowledge they have a genetic disorder.
- C. The child will verbalize age-appropriate feelings of self-worth.
- D. The family will be able to express their concerns.
- E. The child will sign a behavior contract.
- F. The child will learn to isolate when feeling angry.
Correct Answer: A,E,F
Rationale: Correct Answer: A, E, F
Rationale:
A: The child demonstrating effective problem-solving skills is crucial for managing IED episodes.
E: Signing a behavior contract helps set clear expectations and consequences for behavior, aiding in self-regulation.
F: Learning to isolate when feeling angry can prevent harm and give time to calm down, a key skill for managing IED.
Incorrect Choices:
B: Acknowledging a genetic disorder is not relevant to managing IED.
C: While important, verbalizing feelings of self-worth may not directly address the impulsivity of IED.
D: Expressing concerns is valuable but not a direct goal for managing IED.