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A nurse is assessing a client who has opioid withdrawal. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Hyperthermia
- C. Insomnia
- D. Bradycardia
Correct Answer: C
Rationale: The correct answer is C: Insomnia. Opioid withdrawal often presents with symptoms like insomnia due to increased sympathetic activity. Hypotension (A) is less likely as opioids can cause hypertension. Hyperthermia (B) is not typically associated with opioid withdrawal. Bradycardia (D) is also less common, as opioid withdrawal can lead to tachycardia. Insomnia is a hallmark symptom of opioid withdrawal, making it the most appropriate choice.
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A nurse in a psychiatric facility is planning care for a client who has depression and is at risk for suicide. Which of the following interventions should the nurse implement?
- A. Assign the same staff to the client each shift
- B. Keep the client's room well-lit at all times
- C. Allow the client privacy at all times
- D. Provide access to sharp objects
Correct Answer: A
Rationale: The correct answer is A: Assign the same staff to the client each shift. Consistency in staff helps build trust and rapport, crucial for clients with depression and suicide risk. This continuity allows staff to better monitor the client's behavior, mood changes, and suicide risk factors. The familiarity also helps in identifying early warning signs and implementing appropriate interventions promptly.
Choice B is incorrect because while keeping the room well-lit may help prevent self-harm, it does not address the underlying need for consistent support and monitoring.
Choice C is incorrect as constant privacy may hinder the nurse's ability to assess the client's safety and intervene effectively.
Choice D is incorrect as providing access to sharp objects increases the client's risk of self-harm.
A nurse is assessing a client who has histrionic personality disorder. Which of the following findings should the nurse expect?
- A. Lack of remorse
- B. Attention seeking
- C. Splitting of staff
- D. Identity disturbance
Correct Answer: B
Rationale: The correct answer is B: Attention seeking. In histrionic personality disorder, individuals often seek attention by being overly dramatic, seductive, or provocative. This behavior is a key characteristic of the disorder. Lack of remorse (A) is more indicative of antisocial personality disorder. Splitting of staff (C) is more commonly associated with borderline personality disorder. Identity disturbance (D) is a feature of borderline personality disorder as well. In summary, attention seeking behavior is a hallmark trait of histrionic personality disorder, making choice B the correct answer in this scenario.
A nurse is caring for a client with Alzheimer’s disease. Which of the following actions should the nurse take?
- A. Seat the client at a dining table with six or more residents
- B. Provide the client with several choices for meal selection
- C. Give complete directions before starting client care
- D. Use symbols to assist the client in locating rooms
Correct Answer: D
Rationale: The correct answer is D. Using symbols to assist the client in locating rooms is beneficial for a client with Alzheimer's as they may have difficulty remembering locations. Symbols can serve as visual cues to help them navigate and reduce confusion. A: Seating the client at a dining table with multiple residents may be overwhelming and lead to agitation. B: Providing several meal choices can be confusing and increase indecision for someone with Alzheimer's. C: Giving complete directions all at once may be too much information for the client to process. Instead, simple and clear instructions are more effective.
A nurse is providing teaching to a client who has bipolar disorder and a new prescription for lithium. Which of the following instructions should the nurse include?
- A. Take lithium on an empty stomach
- B. Avoid consuming foods high in sodium
- C. Drink 2-3 liters of water daily
- D. Increase caffeine intake
Correct Answer: C
Rationale: The correct answer is C: Drink 2-3 liters of water daily. Lithium is a mood stabilizer that can cause dehydration. Drinking an adequate amount of water helps prevent lithium toxicity and maintain proper kidney function. Choice A is incorrect because lithium should be taken with food to reduce gastrointestinal side effects. Choice B is incorrect because limiting sodium intake is not directly related to lithium therapy. Choice D is incorrect as increasing caffeine intake can lead to dehydration and worsen lithium side effects.
A nurse is preparing to administer chlorpromazine hydrochloride 25 mg PO to an older adult client. Available is chlorpromazine hydrochloride syrup 10 mg/5 mL. How many mL should the nurse administer?
- A. 12.5
- B. 10
- C. 15
- D. 5
Correct Answer: A
Rationale: The correct answer is A: 12.5 mL. To calculate this, we first determine the total amount needed, which is 25 mg. Then, we use the concentration of the syrup, which is 10 mg/5 mL. By setting up a proportion (25 mg = x mL), we can cross multiply to find x, which equals 12.5 mL. Choice B (10 mL) is incorrect because it does not provide the full 25 mg dose. Choices C (15 mL) and D (5 mL) are incorrect as they do not align with the calculated dose based on the concentration of the syrup.