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A nurse is caring for a client who is experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit. Which of the following actions should the nurse take?
- A. Warn the client that further disruptions will result in seclusion.
- B. Ask the client to recommend consequences for her disruptive behavior.
- C. Set limits on the client's behavior and be consistent in approach.
- D. Ignore the client's behavior,realizing it is consistent with her illness.
Correct Answer: C
Rationale: The correct answer is C: Set limits on the client's behavior and be consistent in approach. This is the best course of action because it maintains a therapeutic environment while ensuring the safety and well-being of all clients. By setting limits, the nurse establishes boundaries for acceptable behavior during the manic episode, helping to prevent harm and maintain order on the unit. Consistency in approach is crucial to provide the client with structure and predictability, which can help manage the manic symptoms and reduce potential disruptions.
Choice A is not the best option as it may escalate the situation and does not address the underlying issue. Choice B is not appropriate as it puts the responsibility on the client to determine consequences, which may not be effective in managing the behavior. Choice D is incorrect as ignoring the behavior can compromise the safety of other clients and is not a therapeutic approach to managing manic episodes.
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A nurse is admitting a client with a history of alcohol use disorder. The nurse is aware that which of the following are potential physical symptoms of alcohol withdrawal? (Select all that apply.)
- A. Seizures
- B. Tachycardia
- C. Hallucinations
- D. Tremors
- E. Hypotension
Correct Answer: A,B,C,D
Rationale: The correct answer is A, B, C, and D. Alcohol withdrawal can lead to seizures due to hyperexcitability of the nervous system. Tachycardia is common as alcohol withdrawal can cause increased heart rate and blood pressure. Hallucinations are possible due to disturbances in brain function. Tremors are a typical symptom of alcohol withdrawal, known as "the shakes." Choices E and F, hypotension and G, are not typically associated with alcohol withdrawal. In summary, the correct symptoms are related to central nervous system hyperactivity, while the incorrect choices are not commonly observed in alcohol withdrawal.
A nurse is providing teaching to a client who has an alcohol use disorder about Alcoholics Anonymous (AA). Which of the following client statements indicates an understanding of the program's basic concepts?
- A. I am responsible for my alcoholism.
- B. I am powerless against my addiction to alcohol.
- C. I need to see a counselor who will be responsible for my recovery.
- D. I need to identify things that cause me to be an alcoholic.
Correct Answer: B
Rationale: Admitting powerlessness over alcohol aligns with AA’s first step.
Charles, the nurse, is working in an emergency department and is assessing a preschool-age child who reports abdominal pain. Which of the following findings should alert the nurse to possible abuse (select all that apply)
- A. Areas of ecchymosis on the torso.
- B. Mismatched clothing
- C. Abrasions on knees
- D. Abdominal rebound tenderness
- E. Round burn marks on forearms
Correct Answer: A,E
Rationale: The correct answers are A and E. Ecchymosis on the torso may indicate physical abuse, and burn marks on the forearms suggest possible abuse as well. Mismatched clothing (B) is not a direct indicator of abuse but may suggest neglect. Abrasions on knees (C) are common in preschool-age children and do not specifically point to abuse. Abdominal rebound tenderness (D) is a medical finding that may indicate a health issue but does not directly correlate with abuse. Overall, A and E are the most concerning findings that should alert the nurse to possible abuse.
A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After orienting the client to his room,which of the following nursing actions is most therapeutic at this time?
- A. Have the client join a therapy group.
- B. Remain with the client in his room for a while.
- C. Suggest that the client rest in bed.
- D. Medicate the client with a sedative.
Correct Answer: B
Rationale: The correct answer is B: Remain with the client in his room for a while. This is the most therapeutic action because it provides immediate support and comfort to the client experiencing panic-level anxiety. By staying with the client, the nurse can offer reassurance, help calm the client, and establish a sense of safety and trust. This supportive presence can help the client feel less overwhelmed and reduce feelings of isolation. It also allows the nurse to monitor the client closely for any changes in anxiety levels or behaviors.
Choices A, C, and D are incorrect:
A: Having the client join a therapy group may be overwhelming for someone experiencing panic-level anxiety and may not provide the immediate one-on-one support needed.
C: Suggesting that the client rest in bed does not address the client's emotional needs or provide the necessary support for managing anxiety.
D: Medicating the client with a sedative should not be the first-line intervention for panic-level anxiety as it may mask underlying issues and does not address
A nurse is providing teaching to a client who has hypothyroidism and has been prescribed levothyroxine. Which of the following medication instructions would the nurse include in the teaching?
- A. Take this medication before a meal or several hours after a meal.
- B. Take this medication during your morning meal.
- C. Take this medication with a full glass of water or fruit juice.
- D. Take this medication with high-protein foods.
Correct Answer: A
Rationale: The correct answer is A. Levothyroxine is best absorbed on an empty stomach, so taking it before a meal or several hours after a meal ensures optimal absorption. Taking it with food or certain beverages can interfere with absorption. Choice B is incorrect as taking it during a meal may reduce absorption. Choice C is incorrect as water or fruit juice is recommended, not required in full glass quantity. Choice D is incorrect as high-protein foods can also interfere with absorption.