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A nurse is caring for a client who has a history of opioid use disorder. Which medication should the nurse anticipate administering to prevent withdrawal symptoms?
- A. Methadone
- B. Disulfiram
- C. Naloxone
- D. Bupropion
Correct Answer: A
Rationale: Rationale: A nurse should anticipate administering Methadone to prevent withdrawal symptoms in a client with opioid use disorder. Methadone is a long-acting opioid agonist that helps manage withdrawal symptoms and cravings, making it an effective treatment option. Disulfiram is used for alcohol dependence, Naloxone is an opioid antagonist used for overdose reversal, and Bupropion is an antidepressant. These medications are not indicated for preventing opioid withdrawal symptoms.
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A client with schizophrenia is prescribed risperidone. Which of the following should the nurse monitor for as an adverse effect of this medication?
- A. Increased blood pressure
- B. Weight gain
- C. Excessive salivation
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Weight gain. Risperidone is an antipsychotic medication known to cause metabolic side effects such as weight gain. This is due to its impact on appetite regulation and metabolism. Monitoring weight is crucial to prevent complications such as diabetes and cardiovascular issues.
A: Increased blood pressure is not a common adverse effect of risperidone.
C: Excessive salivation is not a typical side effect of risperidone.
D: Bradycardia is not associated with risperidone use in clients with schizophrenia.
A nurse is admitting a client who has dementia to a long-term care facility. The client tells the nurse that she lived in this facility years ago and took care of all the residents by herself. The nurse should document this as which of the following findings?
- A. Projection
- B. Perseveration
- C. Agnosia
- D. Confabulation
Correct Answer: D
Rationale: The correct answer is D: Confabulation. Confabulation is the creation of false memories or distortion of actual memories without the intention to deceive. In this scenario, the client is not intentionally lying, but rather recalling a memory that did not occur. This is common in individuals with dementia. Projection (A) involves attributing one's thoughts or feelings to someone else. Perseveration (B) is the persistent repetition of a response. Agnosia (C) is the inability to recognize familiar objects or people. In this case, the client's statement aligns most closely with confabulation, making it the correct choice.
A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan?
- A. Encourage the client to lie down in a quiet room.
- B. Refer to the hallucinations as if they are real.
- C. Ask the client directly what he is hearing.
- D. Avoid eye contact with the client.
Correct Answer: C
Rationale: The correct answer is C: Ask the client directly what he is hearing. This action is crucial in assessing the content and severity of the hallucinations, which helps in tailoring appropriate interventions. By directly inquiring about the auditory hallucinations, the nurse demonstrates active listening and shows empathy towards the client's experiences. This approach also fosters a trusting therapeutic relationship.
Choice A: Encouraging the client to lie down in a quiet room does not address the auditory hallucinations directly and may not be effective in managing them.
Choice B: Referring to the hallucinations as if they are real can validate and reinforce the client's delusions, worsening the symptoms.
Choice D: Avoiding eye contact with the client may convey a message of discomfort or disinterest, hindering the establishment of rapport and trust.
In summary, choice C is the most appropriate as it directly addresses the client's symptoms and facilitates a comprehensive assessment, which is essential for developing an effective care plan.
A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase?
- A. We should discuss resources to implement in your daily life.
- B. Let me show you simple relaxation exercises to manage stress.
- C. We should establish our roles in the initial session.
- D. Let's talk about how you can change your response to stress.
Correct Answer: C
Rationale: The correct answer is C: "We should establish our roles in the initial session." During the orientation phase of the therapeutic relationship, it is crucial to clarify the roles of both the nurse and the client to establish boundaries and expectations. This helps set the foundation for a trusting and effective therapeutic alliance. Discussing resources (A) and relaxation exercises (B) are important but typically occur later in the relationship. Talking about changing responses to stress (D) may be premature in the orientation phase. The other choices are not relevant to the specific goal of the orientation phase, which is to define roles and expectations.
A nurse is planning care for a client who has borderline personality disorder and engages in self-mutilation. Which intervention should the nurse include?
- A. Restrict the client's access to personal belongings.
- B. Encourage the client to express feelings of anger.
- C. Place the client in seclusion when self-injurious behavior occurs.
- D. Tell the client to stop the self-mutilation behavior.
Correct Answer: B
Rationale: The correct answer is B: Encourage the client to express feelings of anger. For a client with borderline personality disorder and self-mutilation behavior, it is essential to address underlying emotions. Encouraging the client to express feelings of anger can help them identify and process their emotions, reducing the likelihood of resorting to self-injury. Restricting access to personal belongings (A) may lead to feelings of frustration and exacerbate the behavior. Placing the client in seclusion (C) may cause feelings of abandonment and increase distress. Simply telling the client to stop self-mutilation (D) overlooks the complex emotional reasons behind the behavior.