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A nurse is assessing a client who has a history of alcohol use disorder. Which of the following questions should the nurse include to determine how alcohol use affects the client's psychosocial behaviors?
- A. "Has alcohol use affected your performance at work?"
- B. "Have you received prior treatment for substance use disorder?"
- C. "Do you receive treatment for any mental health disorders?"
- D. "At what age did you begin drinking alcohol?"
Correct Answer: A
Rationale: The correct answer is A. By asking if alcohol use has affected the client's performance at work, the nurse can assess the impact of alcohol on the client's psychosocial behaviors, such as work productivity and relationships with colleagues. This question directly addresses the behavioral consequences of alcohol use.
Explanation for incorrect choices:
B: Asking about prior treatment for substance use disorder focuses on the past rather than the current impact on psychosocial behaviors.
C: Inquiring about treatment for mental health disorders is relevant but does not specifically address the psychosocial effects of alcohol use.
D: Asking at what age the client began drinking alcohol provides historical information but does not assess current psychosocial behaviors.
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A nurse is caring for a client who has a history of alcohol use disorder and has been hospitalized for detoxification. The nurse enters the room and finds the client shouting in a terrified voice, "Get these bugs off of me!” Which of the following responses by the nurse is appropriate?
- A. "I'm sure that the bugs you see will not harm you."
- B. "Tell me more about the bugs that you see in your room."
- C. "I don't see any bugs, but you seem very frightened."
- D. "I do not see anything. This is part of the withdrawal process."
Correct Answer: C
Rationale: Response C is appropriate because it acknowledges the client's feelings without confirming the presence of bugs. This response shows empathy and understanding while not reinforcing the client's hallucination. Response A dismisses the client's fear and may increase anxiety. Response B encourages the client to focus on the hallucination, worsening the distress. Response D invalidates the client's experience and may lead to distrust.
A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client’s head is down, and he is wringing his hands. Which of the following actions should the nurse take?
- A. Encourage the client to go back to bed.
- B. Give the client a PRN sleeping medication.
- C. Remain with the client.
- D. Explore alternatives to pacing the floor with the client.
Correct Answer: C
Rationale: The correct answer is C: Remain with the client. By remaining with the client, the nurse can provide support and reassurance, assess the client's emotional state, and ensure the client's safety. This action shows empathy and promotes therapeutic communication. Encouraging the client to go back to bed (A) may not address the underlying issue causing the restlessness. Giving a PRN sleeping medication (B) without further assessment may not be appropriate and could mask the client's feelings. Exploring alternatives to pacing (D) is a good intervention but should come after providing immediate support and understanding the client's needs.
A nurse is caring for an adolescent female who has an eating disorder. The client is 162.6 cm (64 in) tall and weighs 38.56 kg (85 lb). Upon assessment, which of the following manifestations should the nurse expect? (Select all that apply.)
- A. Amenorrhea
- B. Verbalized desire to gain weight
- C. Altered body image
- D. Hyperactivity
- E. Bradycardia
Correct Answer: A, C, D, E
Rationale: Anorexia nervosa is often associated with amenorrhea, distorted body image, excessive activity, and bradycardia due to malnutrition.
A nurse is discussing the manifestations of alcohol withdrawal with a client who has a history of alcohol use disorder. Which of the following client statements indicates understanding?
- A. "I should expect tremors to start less than 24 hours after I stop drinking."
- B. "Disulfiram will block my cravings for alcohol."
- C. "My symptoms should last about 5 to 7 days once they begin."
- D. "It is important that I take vitamin C to prevent cirrhosis or other liver damage."
Correct Answer: A
Rationale: The correct answer is A because alcohol withdrawal symptoms, including tremors, typically begin within 6-24 hours after the last drink. This statement shows an accurate understanding of the timing of alcohol withdrawal manifestations. Choice B is incorrect because Disulfiram is a medication used to deter alcohol consumption, not block cravings. Choice C is incorrect because alcohol withdrawal symptoms can last beyond 5-7 days. Choice D is incorrect because vitamin C does not prevent cirrhosis or liver damage from alcohol abuse.
A nurse is assessing an adolescent client who has anorexia nervosa. Which of the following client statements is a sign of cognitive distortion?
- A. "I like to cut my food into small pieces."
- B. "I really need to get into shape."
- C. "If I eat one piece of candy, I may as well eat ten."
- D. "I can't afford to gain weight."
Correct Answer: C
Rationale: Cognitive distortions involve irrational thought patterns, such as all-or-nothing thinking.