Nokea
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.
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A nurse is caring for a client who is refusing to attend group therapy. The client states,I don't know why you think I need therapy. I am fine without it. Which of the following responses by the nurse indicates a therapeutic response?
- A. I understand that you feel like you don't need it; however, the provider thinks it will help.
- B. You don't feel like group therapy is for you. Tell me more about what you know about group therapy.
- C. I am not saying that you need therapy, but I am sure it will help you.
- D. You don't have to be afraid to go. Our therapists are very understanding.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Option B demonstrates therapeutic communication by showing empathy and understanding towards the client's feelings and inviting further discussion. By encouraging the client to express their thoughts on group therapy, the nurse opens up a dialogue to explore the client's beliefs and concerns, fostering trust and rapport. This approach respects the client's autonomy and promotes client-centered care.
Summary of Incorrect Choices:
A: This response dismisses the client's feelings and focuses on the provider's opinion, potentially alienating the client and not addressing their concerns.
C: This response minimizes the client's feelings and imposes the nurse's beliefs, which may lead to resistance and hinder the therapeutic relationship.
D: This response invalidates the client's emotions by assuming fear as the underlying issue and may create defensiveness rather than addressing the client's actual concerns.
A nurse is reviewing the history and physical of an adolescent client diagnosed with conduct disorder. The nurse recognizes that which of the following is an expected assessment finding of conduct disorder?
- A. Death of client's father two months ago
- B. Experiences frequent facial tics
- C. Adheres strictly to routines
- D. Suspended from school several times in the past year
Correct Answer: D
Rationale: The correct answer is D: Suspended from school several times in the past year. Conduct disorder is characterized by persistent patterns of behavior that violate the rights of others and societal norms. Being suspended from school multiple times indicates a disregard for rules and authority, which is a common feature of conduct disorder. Choices A, B, and C do not directly align with the typical behaviors associated with conduct disorder. A recent death in the family (A) may lead to emotional distress but is not a defining characteristic of conduct disorder. Frequent facial tics (B) are more indicative of a neurological or psychological condition, not conduct disorder. Adhering strictly to routines (C) is more characteristic of obsessive-compulsive disorder, not conduct disorder.
A nurse is reviewing the medical records of clients on a hospital floor. Which client would the nurse expect is most at risk for hyperthyroidism?
- A. A 45-year-old female who has a family history of autoimmune disorders
- B. A 73-year-old male who has an iodine deficiency
- C. A 25-year-old female who has metabolic syndrome
- D. A 35-year-old male who has Graves' disease
Correct Answer: D
Rationale: The correct answer is D: A 35-year-old male who has Graves' disease. Graves' disease is a common cause of hyperthyroidism characterized by an overactive thyroid gland. Individuals with Graves' disease often present with symptoms such as weight loss, tremors, and palpitations. The autoimmune nature of Graves' disease leads to the production of thyroid-stimulating immunoglobulins, resulting in excess thyroid hormone production. Therefore, a client with a known diagnosis of Graves' disease is at the highest risk for hyperthyroidism.
A: A 45-year-old female with a family history of autoimmune disorders may be at risk for developing autoimmune conditions, including hyperthyroidism, but without a current diagnosis of hyperthyroidism, she is not the most at risk in this scenario.
B: A 73-year-old male with iodine deficiency is more likely to develop hypothyroidism rather than hyperthyroidism, as iodine deficiency is a common cause
A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse?
- A. A child whose parents answer questions for the child
- B. A child who has frequent visitors
- C. A child who has a BMI indicating obesity
- D. A child who uses the call light frequently
Correct Answer: A
Rationale: The correct answer is A. When parents answer questions for the child, it may indicate a lack of autonomy or control over their own care, suggesting potential abuse or neglect. This behavior can be a red flag for the nurse to further assess the child's situation. Choices B, C, and D do not necessarily indicate abuse. Frequent visitors could be a sign of social support, obesity may be due to various factors, and using the call light frequently may indicate medical needs rather than abuse. It is essential for the nurse to explore further if a child's autonomy is being compromised.
A nurse is caring for a newly admitted adolescent client. When asked to describe their social support system,the client responds My mom died last year, and I have been in foster care ever since. I don't have many friends. Which of the following actions should the nurse take?
- A. Tell the client that being in foster care can help with coping.
- B. Explain how grief support groups could increase coping and social support.
- C. Encourage the client to ask the provider for medication.
- D. Suggest using the internet as a source for finding supportive friends.
Correct Answer: B
Rationale: The correct answer is B. The nurse should explain how grief support groups could increase coping and social support. Grief support groups provide a safe space for individuals to share their experiences, receive empathy, and learn coping strategies. This is particularly important for the adolescent client who has experienced significant loss and lacks a strong social support system. By participating in a grief support group, the client can connect with others who have had similar experiences, feel understood, and build new supportive relationships. This intervention addresses the client's need for social support and coping mechanisms.
Choices A, C, and D are incorrect. A: Being in foster care may provide some support, but it does not address the client's specific need for coping with grief and building a social support system. C: Encouraging the client to ask for medication is not appropriate without first exploring non-pharmacological interventions. D: Suggesting the internet as a source for finding friends does not address the client's need for emotional support and may not