Nokea
A nurse is assessing a client who is withdrawing from alcohol. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Tremors
- B. Hyperglycemia
- C. Insomnia
- D. Visual hallucinations
- E. Severe hypotension
Correct Answer: A,C,D
Rationale: Tremors insomnia and hallucinations are typical alcohol withdrawal symptoms.
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A nurse is discussing stress management techniques with a group of clients. Which of the following techniques mentioned by a client should the nurse recognize as the least effective?
- A. I exercise when my neck is tense.
- B. I fix myself a pot of coffee when I get anxious.
- C. I pray when I begin to breathe fast.
- D. I journal when I find it difficult to talk.
Correct Answer: B
Rationale: The correct answer is B. Fixing oneself a pot of coffee when feeling anxious is the least effective stress management technique mentioned. Caffeine in coffee can exacerbate anxiety symptoms due to its stimulant properties, leading to increased heart rate and jitteriness. Exercise (A) helps release tension, prayer (C) promotes relaxation, and journaling (D) aids in expressing emotions. Choosing coffee over these more beneficial techniques can be counterproductive in managing stress.
A nurse is caring for a postoperative client following a total knee replacement. Which of the following medications should the nurse anticipate the provider to prescribe to prevent the formulation of a deep vein thrombosis (DVT)?
- A. Enoxaparin
- B. Alteplase (tPA)
- C. Warfarin
- D. Clopidogrel
Correct Answer: A
Rationale: The correct answer is A: Enoxaparin. Enoxaparin is a low molecular weight heparin that helps prevent deep vein thrombosis (DVT) by inhibiting clot formation. It is commonly prescribed postoperatively for clients undergoing knee replacement surgery due to the increased risk of DVT. Alteplase (tPA) is a thrombolytic agent used to dissolve existing blood clots and not typically used for prevention. Warfarin is an oral anticoagulant that requires monitoring of INR levels and is usually started after initial treatment with heparin. Clopidogrel is an antiplatelet agent and is not typically used for DVT prevention.
A client has made the decision to leave her alcoholic husband and reports feeling very depressed. Which of the following is a non-therapeutic statement by the nurse that demonstrates sympathy?
- A. You are feeling very depressed. I felt the same way when I decided to leave my husband.
- B. I can understand you are feeling depressed. It was a difficult decision. I'll sit with you.
- C. You seem depressed. It was a difficult decision to make. Would you like to talk about it?
- D. I know this is a difficult time for you. Would you like medication for anxiety?
Correct Answer: A
Rationale: The correct answer is A because the nurse is sharing her personal experience, which is not therapeutic as it shifts the focus from the client to the nurse's own experience. This can make the client feel unheard and invalidated. Choice B demonstrates empathy and offers support by acknowledging the client's feelings and offering to sit with them. Choice C also shows empathy and provides an opportunity for the client to talk. Choice D is non-therapeutic as it jumps to suggesting medication without exploring the client's emotions or needs.
A nurse educator is discussing community mental health with a group of nursing students. Based on the public health model,which of the following statements made by one of the students indicates correct information about primary prevention?
- A. Services aimed at reducing the incidence of mental disorders within the population.
- B. Services aimed at reducing the residual defects that are associated with severe and persistent mental illness.
- C. Accomplished through early identification of problems and prompt initiation of effective treatment.
- D. Interventions aimed at minimizing early symptoms of psychiatric illness and directed toward reducing the prevalence and duration of the illness.
Correct Answer: A
Rationale: The correct answer is A. Primary prevention focuses on reducing the incidence of mental disorders within the population by implementing strategies to prevent the development of mental health issues. This is achieved through promoting mental wellness, addressing risk factors, and enhancing protective factors in the community.
Choice B is incorrect as it refers to secondary prevention, which aims to reduce the residual defects associated with existing mental illness. Choice C describes early intervention, which is part of secondary prevention. Choice D is related to tertiary prevention, which involves minimizing symptoms and preventing complications of an existing illness. Overall, only choice A aligns with the concept of primary prevention in community mental health.
A nurse is assessing a client diagnosed with schizophrenia who has been treated with fluphenazine (Prolixin) for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?
- A. Sudden onset of high fever
- B. Twisting tongue movements
- C. Constant tapping of feet when sitting
- D. Shuffling gait
Correct Answer: B
Rationale: Twisting tongue movements are a classic sign of tardive dyskinesia from long-term antipsychotic use.