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A nurse is caring for a client who has posttraumatic stress disorder related to military service. Which of the following actions should the nurse take?
- A. Encourage the client to suppress feelings of trauma
- B. Assign the same staff to care for the client each day
- C. Address the client in an authoritative manner
- D. Limit the amount of time spent with the client
Correct Answer: B
Rationale: The correct answer is B: Assign the same staff to care for the client each day. Consistency in care providers helps establish trust and a sense of safety for clients with PTSD. This familiarity can reduce anxiety and improve therapeutic rapport. Encouraging the client to suppress feelings of trauma (A) can be harmful as it may worsen symptoms. Addressing the client in an authoritative manner (C) can trigger feelings of threat. Limiting time spent with the client (D) can hinder the development of a therapeutic relationship.
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A nurse is assessing a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Visual hallucinations
- C. Hypotension
- D. Hyperactivity
Correct Answer: B
Rationale: The correct answer is B: Visual hallucinations. During alcohol withdrawal, the client may experience hallucinations due to the central nervous system's hyperexcitability. This symptom is typically seen within 12-24 hours of the last drink. Bradycardia (A) and hypotension (C) are less common in alcohol withdrawal; tachycardia and hypertension are more typical. Hyperactivity (D) is not a common symptom and is more likely to be seen in stimulant withdrawal.
A nurse is assessing a child in the emergency department. Which of the following findings places the child at the greatest risk for physical abuse?
- A. The child is 10 years old
- B. The child is home-schooled
- C. The child has no siblings
- D. The child has cystic fibrosis
Correct Answer: A
Rationale: The correct answer is A: The child is 10 years old. Children between 8-12 years old are at higher risk for physical abuse due to increased independence and potential conflicts with caregivers. Being 10 years old puts the child at a critical age for abuse. Choice B (home-schooled) does not directly correlate with an increased risk of abuse. Choice C (no siblings) does not indicate abuse risk. Choice D (cystic fibrosis) is a medical condition and does not specifically increase the risk of physical abuse.
A nurse is caring for a client who has major depressive disorder. After discussing the treatment with his partner, the client verbally agrees to electroconvulsive therapy (ECT) but will not sign the consent form. Which of the following actions should the nurse take?
- A. Request that the client’s partner sign the consent form
- B. Cancel the scheduled ECT procedure
- C. Proceed with the preparation for ECT based on implied consent
- D. Inform the client about the risks of refusing the ECT
Correct Answer: B
Rationale: The correct answer is B: Cancel the scheduled ECT procedure. The nurse must prioritize the autonomy and right to informed consent of the client. Since the client has verbally agreed but will not sign the consent form, it indicates uncertainty or potential coercion. Proceeding without proper documentation could lead to legal and ethical issues. Requesting the partner to sign (A) may not be ethically sound without the client's explicit consent. Proceeding based on implied consent (C) is risky and violates the client's autonomy. Informing the client about risks (D) is important but should not override the need for proper consent. Cancelling the procedure allows time for further discussion and ensures the client's best interest.
A nurse is reviewing laboratory findings for a client who has been taking lithium for 6 months. Which of the following findings should the nurse report to the provider?
- A. Lithium level 0.8 mEq/L
- B. Sodium 130 mEq/L
- C. Creatinine 1.5 mg/dL
- D. WBC 8,000/mm³
Correct Answer: C
Rationale: The correct answer is C: Creatinine 1.5 mg/dL. This finding should be reported because an elevated creatinine level indicates impaired kidney function, which can lead to lithium toxicity. Lithium is primarily excreted by the kidneys, and impaired renal function can result in lithium accumulation in the body, increasing the risk of adverse effects. Reporting this finding promptly will allow the provider to adjust the dosage of lithium to prevent toxicity.
Choices A, B, and D are within normal ranges and do not directly indicate lithium toxicity. A lithium level of 0.8 mEq/L is within the therapeutic range (0.6-1.2 mEq/L). Sodium level of 130 mEq/L is also within normal limits. WBC count of 8,000/mm³ is normal and not directly related to lithium toxicity. Therefore, these findings do not require immediate reporting compared to the elevated creatinine level.
A nurse is evaluating the medication response of a client who takes naltrexone for the treatment of alcohol use disorder. The nurse should identify that which of the following is a therapeutic effect of this medication.
- A. Blocks aldehyde dehydrogenase
- B. Prevents the anxiety of abstinence
- C. Reduces substance craving
- D. Decreases the likelihood of seizures
Correct Answer: C
Rationale: The correct answer is C: Reduces substance craving. Naltrexone is an opioid receptor antagonist that helps reduce the craving for alcohol by blocking the euphoric effects associated with alcohol consumption. This medication does not block aldehyde dehydrogenase (choice A), which is involved in alcohol metabolism. It also does not prevent the anxiety of abstinence (choice B) or decrease the likelihood of seizures (choice D). Naltrexone specifically targets reducing the desire to drink, making choice C the most appropriate therapeutic effect in this scenario.