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A nurse in an emergency department is caring for a client who is experiencing acute alcohol withdrawal. Which of the following actions should the nurse take first?
- A. Implement seizure precautions.
- B. Insert an IV access site.
- C. Obtain a blood specimen.
Correct Answer: A
Rationale: The correct answer is A: Implement seizure precautions. The priority in caring for a client experiencing acute alcohol withdrawal is to prevent potential life-threatening complications like seizures. Implementing seizure precautions involves ensuring a safe environment, such as padding the bed and removing any harmful objects. This step takes precedence over inserting an IV access site (B) or obtaining a blood specimen (C) because seizures pose an immediate risk to the client's safety. It is crucial to address the most urgent need first to ensure the client's well-being.
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A nurse in an acute care facility is admitting an older adult client who has dementia due to Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his wife. Which of the following interventions is the nurse’s priority?
- A. Recommend that the partner place the client in a long-term care facility.
- B. Suggest that the partner see a counselor to help him cope with his exhaustion.
- C. Ask the partner to talk about his difficulties in caring for the client.
- D. Tell the partner to call a family meeting to get help.
Correct Answer: C
Rationale: Rationale: The correct answer is C - Ask the partner to talk about his difficulties in caring for the client. This is the priority intervention as it allows the nurse to assess the partner's needs, provide emotional support, and gather information to develop a plan for support. By actively listening to the partner's concerns, the nurse can address immediate issues and provide resources for assistance. Other options (A) recommending long-term care, (B) suggesting counseling, and (D) calling a family meeting are important but not the priority as they do not directly address the partner's immediate emotional and practical needs. It is essential to prioritize addressing the partner's exhaustion and emotional well-being to ensure holistic care for both the client with dementia and their caregiver.
A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia. The client's parents are tearful and express feelings of guilt. Which of the following statements should the nurse make?
- A. "You said that you feel guilty about your daughter's diagnosis. Let's talk about what is causing you to feel this way."
- B. "You should not feel guilty about your daughter's diagnosis. Schizophrenia is unpreventable."
- C. "I’m sure your daughter’s diagnosis is very difficult to deal with, but everything will be all right once she receives the proper treatment."
- D. "Your provider has explained the causes of schizophrenia. Why do you feel guilty about your daughter's diagnosis?"
Correct Answer: A
Rationale: Encouraging the parents to discuss their feelings helps with emotional processing and coping.
A nurse is assessing a client who has a mood disorder to determine his readiness for discharge. Which of the following statements by the client indicates he is ready for discharge?
- A. "Right now, I can't bathe or dress myself, but that's not important."
- B. "When I get home, I'm going to let the people who put me here know how angry I am."
- C. "I will take my medicines as I should and know to call the number you gave me if I have bad thoughts."
- D. "Taking care of myself is important, but it's okay if I want to take a break and not do anything."
Correct Answer: C
Rationale: Adherence to medication and awareness of emergency contacts indicate readiness for discharge.
A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE), the nurse should include which of the following data? (Select all that apply.)
- A. Ability to perform calculations
- B. Coping skills
- C. Recall ability
- D. Long-term memory
- E. Level of orientation
Correct Answer: A, C, D, E
Rationale: The correct answers are A, C, D, and E. In a Mental Status Examination for a client with dementia, assessing the ability to perform calculations (A) is important to evaluate cognitive function. Recall ability (C) is crucial as memory impairment is a common feature of dementia. Long-term memory (D) is essential to assess for signs of cognitive decline. The level of orientation (E) is vital to determine the client's awareness of time, place, and person, which can be impaired in dementia. Coping skills (B) are important but not typically assessed in an MSE for dementia. The other choices (F, G) do not directly relate to the cognitive impairment typically seen in dementia.
A nurse in an emergency department is assessing a client for suspected cocaine intoxication. Which of the following findings should the nurse expect?
- A. Nystagmus
- B. Dilated pupils
- C. Hypersomnia
- D. Depression
Correct Answer: B
Rationale: The correct answer is B: Dilated pupils. Cocaine intoxication typically presents with dilated pupils due to the drug's stimulant effects on the sympathetic nervous system. This causes pupil dilation by increasing the release of norepinephrine. Nystagmus (choice A) is not a common finding in cocaine intoxication. Hypersomnia (choice C) is unlikely as cocaine is a stimulant that often leads to decreased need for sleep. Depression (choice D) is not a typical symptom of cocaine intoxication. In summary, dilated pupils are a key indicator of cocaine intoxication, while nystagmus, hypersomnia, and depression are not characteristic findings.