Nokea
A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens. Which of the following actions should the nurse take first?
- A. Administer diazepam.
- B. Raise the side rails of the bed.
- C. Obtain a medical history.
- D. Start intravenous fluids.
Correct Answer: A
Rationale: The correct answer is A: Administer diazepam. Delirium tremens is associated with severe alcohol withdrawal and can be life-threatening. Diazepam is a benzodiazepine used to manage alcohol withdrawal symptoms by reducing agitation and preventing seizures. Administering diazepam first is crucial to stabilize the client's condition and prevent complications. Raising the side rails of the bed (B) can be important for safety but does not address the immediate medical need. Obtaining a medical history (C) is important for understanding the client's background but is not the priority in this acute situation. Starting intravenous fluids (D) may be necessary to address dehydration, but managing the withdrawal symptoms with diazepam takes precedence.
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A nurse is providing teaching for a client who has major depressive disorder and is seeking voluntary admission to an acute mental health facility. Which of the following statements should the nurse include?
- A. "You will give up your right to refuse antidepressant medications upon admission."
- B. "Your provider is required to notify your employer of your admission."
- C. "You will still need to give informed consent for treatments after admission."
- D. "You cannot leave the facility until your provider completes a discharge summary."
Correct Answer: C
Rationale: The correct answer is C: "You will still need to give informed consent for treatments after admission." This statement is important to include in teaching because even after being admitted to a mental health facility, the client retains the right to give informed consent for any treatments or interventions. It emphasizes the client's autonomy and involvement in decision-making regarding their care.
The other options are incorrect:
A: "You will give up your right to refuse antidepressant medications upon admission." This statement is incorrect as the client still has the right to refuse specific treatments even after admission.
B: "Your provider is required to notify your employer of your admission." This statement is incorrect as confidentiality laws protect the client's privacy and do not require notification to the employer.
D: "You cannot leave the facility until your provider completes a discharge summary." This statement is incorrect as the client has the right to leave the facility against medical advice, although there may be consequences or processes to follow.
A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first?
- A. Implement the client's behavioral modification plan.
- B. Document the size and location of the cuts.
- C. Assess the client's intent and suicide risk.
- D. Administer a tetanus antitoxin.
Correct Answer: C
Rationale: The correct answer is C: Assess the client's intent and suicide risk. This is the first action the nurse should take to ensure the immediate safety of the client. By assessing the client's intent and suicide risk, the nurse can determine the severity of the situation and the appropriate level of intervention needed. This assessment will guide the nurse in developing a safety plan to prevent further self-harm or potential suicide attempts.
Choice A is incorrect because implementing the client's behavioral modification plan is not the priority when the client is actively engaging in self-harm behavior.
Choice B is incorrect as documenting the size and location of the cuts can be done after ensuring the client's immediate safety.
Choice D is incorrect as administering a tetanus antitoxin is not the priority in this situation and does not address the client's emotional and psychological needs.
In summary, assessing the client's intent and suicide risk is the most critical step to ensure the client's safety and well-being in a situation involving self-h
A nurse is caring for an adolescent who is experiencing indications of depression. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Irritability
- B. Euphoria
- C. Chronic pain
- D. Social withdrawal
- E. Changes in appetite
Correct Answer: A, C, D, E
Rationale: Depression in adolescents often presents with irritability, physical complaints (chronic pain), social withdrawal, and appetite changes.
A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (Select all that apply.)
- A. Urinary retention and constipation
- B. Tongue thrusting and lip smacking
- C. Fine hand tremors and pill rolling
- D. Facial grimacing and eye blinking
- E. Involuntary pelvic rocking and hip thrusting movements
Correct Answer: B, D, E
Rationale: Tardive dyskinesia involves involuntary repetitive movements such as lip smacking, facial grimacing, and pelvic rocking.
A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect?
- A. Prior physical health followed by the need for two surgeries within the last three months.
- B. Obsession over a fictitious defect in physical appearance.
- C. Sudden unexplained loss of peripheral sensation.
- D. Constant worry about the undiagnosed presence of an illness.
Correct Answer: D
Rationale: The correct answer is D because individuals with illness anxiety disorder experience persistent and excessive worry about having a serious medical condition despite reassurance from healthcare providers. This constant preoccupation with the possibility of being sick is a key characteristic of the disorder. Option A is incorrect as surgeries do not directly relate to illness anxiety disorder. Option B describes body dysmorphic disorder, not illness anxiety disorder. Option C does not align with the typical presentation of illness anxiety disorder.