Nokea
A nurse is assessing a client who is withdrawing from heroin. Which of the following manifestations should the nurse expect?
- A. Slurred speech
- B. Hypotension
- C. Bradycardia
- D. Hyperthermia
Correct Answer: D
Rationale: The correct answer is D: Hyperthermia. Heroin withdrawal can lead to hyperthermia due to increased metabolic activity, dehydration, and dysregulation of the body's temperature control mechanisms. Slurred speech (A) is not a typical manifestation of heroin withdrawal. Hypotension (B) and bradycardia (C) are more commonly associated with opioid overdose rather than withdrawal. In withdrawal, the client may actually experience hypertension and tachycardia due to increased sympathetic activity.
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A nurse is reviewing the medical records for clients. Which of the following findings should the nurse identify as a risk factor for violent behavior?
- A. Schizoid personality disorder
- B. Alcohol intoxication
- C. Dysthymic disorder
- D. Long-term isolation
Correct Answer: B
Rationale: The correct answer is B: Alcohol intoxication. Alcohol intoxication can impair judgment, lower inhibitions, and increase aggression, leading to a higher risk of violent behavior. Schizoid personality disorder (A) is characterized by social detachment, not necessarily violence. Dysthymic disorder (C) involves chronic low mood but not a direct risk for violent behavior. Long-term isolation (D) may contribute to mental health issues but does not directly indicate violent behavior.
A nurse is counseling an adult client whose parent just died. The client states, 'My son is 4, and I don’t know how he’ll react when he finds out that grandpa died.' The nurse should inform the client that the preschool-age child commonly has which of the following concepts of death?
- A. Death is not permanent and the loved one may come back to life
- B. Death is contagious and can cause other people he loves to die
- C. Death creates an interest in the physical aspects of dying
- D. Death is a part of life that eventually happens to everyone
Correct Answer: A
Rationale: The correct answer is A: Death is not permanent and the loved one may come back to life. Preschool-age children often have an understanding of death as temporary, believing that the deceased may come back to life. This is due to their cognitive development and limited understanding of the finality of death. Other choices are incorrect: B is incorrect as children do not typically view death as contagious; C is incorrect as preschoolers often lack a detailed interest in the physical aspects of dying; D is incorrect as preschoolers may not fully grasp the concept of death being a natural part of life.
A nurse is planning care for a client who has bipolar disorder. The client reports not sleeping for 3 days and is exhibiting a euphoric mood. The nurse should identify which of the following as the priority intervention.
- A. Secure the client’s valuable possessions
- B. Limit loud noises in the client’s environment
- C. Encourage the client to participate in structured solitary activities
- D. Provide high calorie snacks to the client
Correct Answer: D
Rationale: The correct answer is D: Provide high calorie snacks to the client. The priority intervention in this scenario is to address the client's lack of sleep and increased energy levels due to mania. Providing high-calorie snacks can help stabilize blood sugar levels and provide sustained energy, potentially aiding in promoting sleep. The other choices are incorrect because securing valuable possessions, limiting loud noises, and encouraging solitary activities do not directly address the immediate need to manage the client's symptoms related to lack of sleep and euphoria.
A nurse is caring for a client who has obsessive-compulsive disorder and engages in repeated handwashing. Which of the following actions should the nurse take?
- A. Encourage the client to stop washing hands
- B. Allow the client additional time to complete rituals
- C. Set strict time limits on compulsions
- D. Ignore the client’s compulsive behavior
Correct Answer: B
Rationale: The correct answer is B: Allow the client additional time to complete rituals. This approach is known as a harm reduction strategy in managing obsessive-compulsive disorder. By allowing the client additional time to complete rituals, the nurse can help reduce the client's anxiety and provide a sense of control. Encouraging the client to stop washing hands (A) may increase anxiety and worsen symptoms. Setting strict time limits on compulsions (C) can also increase anxiety and lead to distress. Ignoring the client's compulsive behavior (D) can be harmful as it may reinforce the behavior. It is important for the nurse to be supportive and understanding of the client's struggles while working towards more effective coping strategies.
A nurse is caring for a client who has schizophrenia and takes clozapine. Which of the following findings is a priority for the nurse to report to the provider?
- A. Nausea
- B. Random blood glucose 130 mg/dL
- C. Heart rate 104 per minute
- D. Sore throat
Correct Answer: D
Rationale: The correct answer is D: Sore throat. A priority finding to report with clozapine is agranulocytosis, which presents with symptoms like sore throat. This is crucial to detect early to prevent severe infection. A: Nausea is a common side effect of clozapine but not a priority over potential agranulocytosis. B: Random blood glucose of 130 mg/dL is slightly elevated but not an immediate concern. C: Heart rate of 104 per minute may be a side effect but is not as critical as agranulocytosis. Reporting the sore throat promptly can lead to timely intervention and prevent serious complications.