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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 expect to administer?
- A. Methadone
- B. Disulfiram
- C. Lorazepam
- D. Bupropion
Correct Answer: C
Rationale: The correct answer is C: Lorazepam. Lorazepam is a benzodiazepine used to manage alcohol withdrawal symptoms by reducing anxiety, insomnia, and seizures. It helps stabilize the client during detoxification. Methadone (A) is used for opioid withdrawal, Disulfiram (B) is a deterrent for alcohol consumption, and Bupropion (D) is used for smoking cessation.
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A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
- A. Replace the carpet with hardwood floors.
- B. Encourage physical activity prior to bedtime.
- C. Wear clothing with zippers instead of buttons.
- D. Place locks at the tops of exterior doors.
Correct Answer: D
Rationale: The correct answer is D: Place locks at the tops of exterior doors. This is important for the safety of a client with Alzheimer's disease who may wander. Placing locks at the tops of doors can prevent the client from easily opening them and wandering off, which is a common behavior in Alzheimer's patients.
A: Replacing carpet with hardwood floors may not directly address the safety concern of wandering.
B: Encouraging physical activity prior to bedtime may help with sleep but does not address the safety issue of wandering.
C: Wearing clothing with zippers instead of buttons may be easier for the client to manage, but it does not address the safety concern of wandering.
Summary: The key consideration in caring for a client with Alzheimer's disease is ensuring their safety, particularly in preventing wandering, which is why placing locks at the tops of exterior doors is the most appropriate action.
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, an atypical antipsychotic, is known to cause metabolic side effects such as weight gain. This occurs due to its effects on increasing appetite and altering metabolism. Monitoring weight regularly is crucial to detect and manage this adverse effect to prevent complications like diabetes and cardiovascular issues. Increased blood pressure (A) is not a common adverse effect of risperidone. Excessive salivation (C) is more commonly associated with medications like clozapine. Bradycardia (D) is not a typical side effect of risperidone.
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 caring for a client with major depressive disorder who has a new prescription for fluoxetine. Which statement by the client indicates an understanding of the medication?
- A. I should expect to see improvement in my mood within a few days.
- B. I may experience increased thoughts of suicide at the beginning of treatment.
- C. I need to avoid foods high in tyramine while taking this medication.
- D. I will need to have my lithium levels checked regularly.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Fluoxetine is an antidepressant that can initially increase suicidal thoughts in some individuals, especially at the beginning of treatment.
2. This phenomenon is known as "activation syndrome" and is important for clients to be aware of.
3. Monitoring for any signs of increased suicidal thoughts is crucial for client safety.
4. Options A, C, and D are incorrect because fluoxetine does not provide immediate mood improvement, does not require avoiding tyramine-rich foods, and does not affect lithium levels.
A nurse is teaching a client who has generalized anxiety disorder about buspirone. Which statement indicates the client understands the teaching?
- A. I should take this medication as needed for acute anxiety.
- B. I may experience sedation and drowsiness with this medication.
- C. I should avoid grapefruit juice while taking this medication.
- D. This medication has a risk for dependence.
Correct Answer: C
Rationale: The correct answer is C because grapefruit juice can interact with buspirone, leading to an increased risk of side effects. Taking the medication with grapefruit juice can affect its absorption and metabolism, potentially altering its effectiveness. Choice A is incorrect because buspirone is typically taken regularly, not as needed. Choice B is incorrect because buspirone is not known for causing significant sedation or drowsiness. Choice D is incorrect because buspirone is not associated with a risk for dependence.