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A nurse is assessing a client who has opioid intoxication. Which of the following findings should the nurse expect?
- A. Pinpoint pupils
- B. Hyperreflexia
- C. Increased respiratory rate
- D. Dilated pupils
Correct Answer: A
Rationale: The correct answer is A: Pinpoint pupils. Opioid intoxication causes miosis, resulting in constricted or pinpoint pupils. This occurs due to the suppression of the sympathetic nervous system. Hyperreflexia (B) is not typically associated with opioid intoxication; it is more common in conditions like spinal cord injury. Opioids depress the respiratory system, leading to decreased respiratory rate (C), not increased. Dilated pupils (D) are more indicative of stimulant intoxication, such as amphetamines.
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A nurse is developing a plan of care for a client who has borderline personality disorder and exhibits manipulative behavior. Which of the following interventions should the nurse include?
- A. Encourage flexibility with unit rules
- B. Implement consistent limit-setting
- C. Allow the client to negotiate consequences
- D. Avoid addressing manipulative behavior
Correct Answer: B
Rationale: The correct answer is B: Implement consistent limit-setting. For clients with borderline personality disorder and manipulative behavior, consistent limit-setting helps establish boundaries and promote a sense of security. By enforcing clear and consistent rules, the nurse can prevent manipulation and maintain a therapeutic environment. Encouraging flexibility with unit rules (choice A) may enable manipulation and disrupt the treatment process. Allowing the client to negotiate consequences (choice C) can reinforce manipulative behaviors. Avoiding addressing manipulative behavior (choice D) can lead to escalation and reinforcement of maladaptive behaviors.
A school nurse is caring for an adolescent client whose teacher reports changes in school performance and withdrawal from interaction with classmates. Which of the following interventions is the nurse’s priority at this time?
- A. Contact the adolescent’s parents
- B. Suggest the adolescent join support groups
- C. Ask the adolescent if he is considering hurting himself
- D. Determine when the adolescent’s change in behavior began
Correct Answer: C
Rationale: The correct answer is C: Ask the adolescent if he is considering hurting himself. This is the priority intervention because it addresses the immediate safety and well-being of the adolescent. By directly asking about thoughts of self-harm, the nurse can assess the risk of suicide and provide appropriate interventions if necessary. Contacting the parents (choice A) can be important but not the priority in this situation. Suggesting support groups (choice B) and determining when the behavior changes began (choice D) are important steps but not as urgent as assessing for suicidal ideation.
A nurse is providing teaching for a school-age child and his parents regarding a new prescription for risperidone. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will provide a low sodium diet for my son
- B. I will make sure my son takes the last dose of the day by 4 PM
- C. I should expect my son to develop hand tremors
- D. I should contact my doctor if my son urinates excessively
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Risperidone is known to cause sedation, so giving the last dose early can help minimize sleep disturbance.
2. Taking the last dose by 4 PM reduces the risk of insomnia or disrupted sleep patterns.
3. This statement shows the parent understands the importance of timing to optimize the medication's effects.
4. The other choices are incorrect because they do not directly relate to the appropriate use of risperidone.
A nurse is providing teaching to a client who has panic disorder and is receiving alprazolam. Which of the following instructions should the nurse include?
- A. Take the medication on an empty stomach
- B. Avoid activities that require alertness
- C. Stop taking the medication if dizziness occurs
- D. Take an additional dose if anxiety increases
Correct Answer: B
Rationale: The correct answer is B: Avoid activities that require alertness. This is important because alprazolam is a benzodiazepine that can cause drowsiness and impair cognitive function. By avoiding activities that require alertness, the client can prevent accidents or injuries.
A: Taking the medication on an empty stomach is not necessary for alprazolam.
C: Stopping the medication if dizziness occurs is not recommended without consulting a healthcare provider.
D: Taking an additional dose if anxiety increases can lead to overdose and is not safe.
Therefore, choice B is the most appropriate instruction to include in teaching the client with panic disorder taking alprazolam.
A nursing is advising an assistive personnel (AP) on the care of a client who has major depressive disorder. The AP states that he is irritated by the client’s depression. Which of the following statements by the nurse is appropriate?
- A. Please don’t take what the client said seriously when she is depressed
- B. It’s important that the client feel safe verbalizing how she is feeling
- C. Everybody feels that way about this client so don’t worry about it
- D. I’ll change your assignment to someone who doesn’t have depressive disorder
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Changing the AP's assignment is appropriate because it addresses the issue of the AP's irritation towards the client's depression. It ensures the client's care is not compromised and maintains a supportive environment. This action also prevents negative attitudes from affecting the client's well-being.
Summary of other choices:
A: Incorrect. Minimizing the client's feelings is inappropriate and may invalidate their experiences.
B: Incorrect. While it is important for the client to verbalize feelings, the focus here is on addressing the AP's behavior.
C: Incorrect. Dismissing the AP's feelings and normalizing negative attitudes are not appropriate responses.
E, F, G: Not provided, but based on the context, they are likely to be irrelevant or inappropriate responses.