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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 assessing a client who has alcohol use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Visual hallucinations
- C. Hyperactivity
- D. Increased appetite
Correct Answer: B
Rationale: The correct answer is B: Visual hallucinations. During alcohol withdrawal, the client may experience hallucinations, particularly visual ones, due to the impact of alcohol on the brain. This is known as alcohol hallucinosis. Hypotension (choice A) is not typically associated with alcohol withdrawal; in fact, hypertension is more common. Hyperactivity (choice C) is not a common symptom of alcohol withdrawal, as clients tend to be more agitated or restless. Increased appetite (choice D) is also not a typical finding during alcohol withdrawal, as many clients experience decreased appetite. Visual hallucinations are a key symptom to monitor for during alcohol withdrawal due to their potential to be distressing and require immediate intervention.
A nurse is assessing a newly admitted client who has schizophrenia and takes thioridazine. Which of the following findings should the nurse document as an adverse effect of this medication?
- A. Anhedonia
- B. Waxy flexibility
- C. Contractions of the jaw
- D. Incongruent affect
Correct Answer: C
Rationale: The correct answer is C: Contractions of the jaw. Thioridazine is an antipsychotic medication known to cause extrapyramidal side effects such as dystonia, which can manifest as contractions of the jaw. Anhedonia (A) is the inability to experience pleasure, not a side effect of thioridazine. Waxy flexibility (B) is a symptom of catatonia, not a side effect of thioridazine. Incongruent affect (D) refers to a mismatch between expression and emotion, not a side effect of thioridazine.
A nurse is developing a plan of care for a client who has post-traumatic stress disorder. Which of the following interventions should the nurse include?
- A. Encourage the client to suppress traumatic memories
- B. Discourage the client from discussing the trauma
- C. Encourage the client to use relaxation techniques
- D. Limit the client’s participation in activities
Correct Answer: C
Rationale: The correct answer is C: Encourage the client to use relaxation techniques. This is important in managing symptoms of PTSD by helping the client to reduce anxiety and stress levels. Relaxation techniques, such as deep breathing and mindfulness, can help the client cope with distressing thoughts and emotions. Encouraging the client to use these techniques promotes self-soothing and emotional regulation.
Choice A is incorrect because suppressing traumatic memories can worsen symptoms and lead to increased distress. Choice B is incorrect as discussing the trauma in a safe and supportive environment is a key component of PTSD therapy. Choice D is incorrect as limiting activities can hinder the client's recovery process.
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 planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include?
- A. Encourage group activities
- B. Provide frequent rest periods
- C. Offer high-calorie snacks
- D. Allow unlimited physical activity
Correct Answer: B
Rationale: The correct answer is B: Provide frequent rest periods. During manic episodes in bipolar disorder, individuals have high energy levels, reduced need for sleep, and increased activity levels. Providing frequent rest periods helps prevent exhaustion and promotes relaxation, which can help stabilize mood. Encouraging group activities (A) may exacerbate manic symptoms due to increased stimulation. Offering high-calorie snacks (C) can lead to poor dietary choices and worsen physical health. Allowing unlimited physical activity (D) can be dangerous as individuals in a manic state may engage in risky behaviors.