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A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. Which of the following medications should the nurse administer?
- A. Methadone
- B. Chlordiazepoxide
- C. Naltrexone
- D. Disulfiram
Correct Answer: B
Rationale: The correct answer is B: Chlordiazepoxide. This medication is a benzodiazepine used to manage alcohol withdrawal symptoms by reducing anxiety, agitation, and preventing seizures. Benzodiazepines help to stabilize the central nervous system during alcohol withdrawal, making it the appropriate choice for this client.
Incorrect Choices:
A: Methadone is used for opioid withdrawal, not alcohol withdrawal.
C: Naltrexone is used for alcohol dependence treatment by reducing cravings, not for acute withdrawal symptoms.
D: Disulfiram is used as a deterrent for alcohol consumption, not for managing withdrawal symptoms.
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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 providing teaching to a client who has depression and a new prescription for amitriptyline. Which of the following statements should the nurse include?
- A. Take this medication at bedtime
- B. Expect to see improvement within 24 hours
- C. Avoid eating foods high in tyramine
- D. Stop the medication once you feel better
Correct Answer: A
Rationale: The correct answer is A: Take this medication at bedtime. Amitriptyline is a tricyclic antidepressant that can cause drowsiness and sedation, so taking it at bedtime can help minimize these side effects. It also helps improve adherence to the medication regimen. Choice B is incorrect because it takes several weeks to see the full effects of amitriptyline, not within 24 hours. Choice C is incorrect because tyramine restriction is typically associated with MAOIs, not tricyclic antidepressants like amitriptyline. Choice D is incorrect because abruptly stopping amitriptyline can lead to withdrawal symptoms and a potential relapse of depression.
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 planning care for a client who has experienced intimate partner abuse. The nurse should identify which of the following outcomes as the priority?
- A. The client joins a support group
- B. The client identifies techniques to reduce stress
- C. The client develops a safety plan
- D. The client identifies support systems
Correct Answer: C
Rationale: The correct answer is C: The client develops a safety plan. This is the priority outcome because it addresses the immediate safety of the client who is experiencing intimate partner abuse. A safety plan helps the client to identify strategies to protect themselves and seek help in times of danger. Joining a support group (A), identifying stress reduction techniques (B), and identifying support systems (D) are important steps in the client's overall recovery process but addressing safety concerns is crucial to prevent further harm. It is important to prioritize safety before addressing other aspects of the client's well-being.
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.