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A nurse is caring for a client who is experiencing a situational crisis. Which of the following actions should the nurse take first?
- A. Assist with a client referral for social services.
- B. Identify if the client has thoughts of self-harm.
- C. Reinforce teaching on the client's use of coping skills.
- D. Encourage the client to use personal support systems.
Correct Answer: B
Rationale: Identifying thoughts of self-harm is crucial for immediate safety and risk management, making it the priority action. This ensures the client’s well-being is secured before addressing other needs.
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A nurse in a substance use disorder clinic is explaining the alcohol recovery process to a client's family. Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder?
- A. Form a close support network.
- B. Acknowledge an inability to control drinking.
- C. Incorporate a form of spirituality into daily life.
- D. Agree to a prescription for an alcohol use deterrent.
Correct Answer: B
Rationale: Acknowledging an inability to control drinking is crucial as it represents acceptance of the problem. Without this self-awareness, the individual is unlikely to seek or benefit from treatment options. This step is foundational, preceding the use of support networks, spirituality, or medication.
A nurse is reinforcing teaching with a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
- A. I can discuss a client's information with staff who have provided care in the past.
- B. A client retains the legal right to privacy of health information even after they have died.
- C. The provider must give consent to discuss health information with the client's family.
- D. A provider may speak to a client's employer regarding a substance use disorder.
Correct Answer: B
Rationale: Clients retain the legal right to privacy of health information even after death, per HIPAA regulations. This statement reflects an accurate understanding of confidentiality principles.
A nurse is collecting data from a client who has schizophrenia. Which of the following client statements indicates that the client is experiencing a command hallucination?
- A. Can you see these spiders crawling all over me?
- B. The aliens are going to abduct me tonight.
- C. Are you planning to kill me?
- D. The voices told me to quit eating the food here.
Correct Answer: D
Rationale: The statement 'The voices told me to quit eating the food here' is indicative of a command hallucination, where the client hears voices instructing them to take specific actions. This distinguishes it from visual hallucinations or delusions.
A nurse is caring for a client who has an opioid use disorder. The nurse should anticipate that the provider will prescribe which of the following medications for treatment?
- A. Phenobarbital.
- B. Diazepam.
- C. Chlordiazepoxide.
- D. Buprenorphine.
Correct Answer: D
Rationale: Buprenorphine is a partial opioid agonist used in medication-assisted treatment for opioid use disorder, helping to reduce cravings and withdrawal symptoms. It’s specifically indicated for this condition.
A nurse is caring for a group of clients in a pediatric clinic. Which of the following clients is at highest risk for physical abuse?
- A. An adolescent who is preparing to leave home for college.
- B. A preschooler who is reluctant to share.
- C. A school-age child who wants to go away to summer camp.
- D. A toddler who has cystic fibrosis.
Correct Answer: D
Rationale: Toddlers with chronic illnesses like cystic fibrosis may be at higher risk for physical abuse due to the increased stress and demands on caregivers. This vulnerability elevates their risk compared to typically developing peers.