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A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings should the nurse expect?
- A. Hand tremors
- B. Stuporous level of consciousness
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: The correct answer is A: Hand tremors. During acute alcohol withdrawal, the central nervous system is hyperexcitable due to the sudden absence of alcohol. This can lead to symptoms such as hand tremors, anxiety, agitation, and even seizures. Stuporous level of consciousness (choice B) is not expected in alcohol withdrawal, as clients typically exhibit hyperactivity. Bradycardia (choice C) and hypotension (choice D) are unlikely findings, as alcohol withdrawal commonly causes increased heart rate and blood pressure due to sympathetic nervous system activation.
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A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining weight. Which of the following nursing actions should the nurse take?
- A. Praise the client for looking at herself in a mirror.
- B. Ask the client to agree to talk to a nurse whenever she feels the urge to exercise.
- C. Reprimand the client about the potential damage that has occurred due to overexercising.
- D. Restrict the client from being weighed.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Asking the client to agree to talk to a nurse whenever she feels the urge to exercise is the most appropriate action. This approach promotes open communication and allows for timely intervention to address the client's excessive exercise behavior. It also demonstrates empathy and support, which are crucial in managing anorexia nervosa. By creating a safe space for the client to express her feelings, the nurse can help prevent further harm caused by overexercising.
Summary of other choices:
A: Praising the client for looking at herself in a mirror may reinforce distorted body image perceptions and unhealthy behaviors.
C: Reprimanding the client could lead to feelings of guilt and shame, exacerbating the client's condition.
D: Restricting the client from being weighed may not address the underlying issue of overexercising and can contribute to feelings of lack of control.
A nurse is caring for a client who has a depressive disorder. The client states, "I just can't feel any happiness or joy in life." Which of the following terms should the nurse use when documenting this finding?
- A. Anhedonia
- B. Anergia
- C. Anosognosia
- D. Akathisia
Correct Answer: A
Rationale: The correct answer is A: Anhedonia. Anhedonia refers to the inability to experience pleasure or joy, which is a common symptom of depressive disorders. In this case, the client's statement of not feeling happiness or joy directly aligns with the definition of anhedonia.
Choice B, Anergia, refers to lack of energy or motivation, which is not directly related to the client's statement about not feeling happiness or joy. Choice C, Anosognosia, is a lack of awareness or insight into one's own condition, which is not applicable in this scenario. Choice D, Akathisia, refers to a movement disorder characterized by restlessness, which is not related to the client's emotional state.
In summary, Anhedonia is the most appropriate term to use when documenting the client's inability to feel happiness or joy, as it directly reflects their emotional experience in the context of a depressive disorder.
A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client’s head is down, and he is wringing his hands. Which of the following actions should the nurse take?
- A. Encourage the client to go back to bed.
- B. Give the client a PRN sleeping medication.
- C. Remain with the client.
- D. Explore alternatives to pacing the floor with the client.
Correct Answer: C
Rationale: The correct answer is C: Remain with the client. By remaining with the client, the nurse can provide support and reassurance, assess the client's emotional state, and ensure the client's safety. This action shows empathy and promotes therapeutic communication. Encouraging the client to go back to bed (A) may not address the underlying issue causing the restlessness. Giving a PRN sleeping medication (B) without further assessment may not be appropriate and could mask the client's feelings. Exploring alternatives to pacing (D) is a good intervention but should come after providing immediate support and understanding the client's needs.
A client who has major depressive disorder states to the nurse that he and his family would be better off if he were gone. Which of the following is the nurse’s priority response?
- A. "Do you really think your family would be better off without you?"
- B. "Tell me what is happening right now."
- C. "Have you thought of harming yourself?"
- D. "When did you first start feeling this way?"
Correct Answer: C
Rationale: The correct answer is C: "Have you thought of harming yourself?" because it addresses the immediate safety concern of suicidal ideation. It is crucial to assess the client's risk of self-harm or suicide first. Choice A is not a direct inquiry about self-harm. Choice B focuses on the current situation but does not address the suicidal statement. Choice D is more about exploring the history of depressive symptoms rather than assessing immediate risk.
A nurse is caring for a client who is hospitalized for the treatment of severe depression. Which of the following nursing approaches is therapeutic to include in the client's plan of care?
- A. Encouraging decision-making
- B. Playing a game of chess with the client
- C. Giving the client choices of activities
- D. Spending time sitting with the client
Correct Answer: D
Rationale: The correct answer is D: Spending time sitting with the client. This approach is therapeutic as it promotes a sense of companionship, support, and comfort for the client. By being present and engaged in the moment, the nurse can establish trust and demonstrate empathy towards the client, which are crucial in the treatment of severe depression. This approach also provides an opportunity for the client to express their feelings and thoughts in a safe and non-judgmental environment.
Choice A, encouraging decision-making, may overwhelm the client who is dealing with severe depression and may exacerbate their feelings of helplessness. Choice B, playing a game of chess, may be too stimulating or competitive for the client in this vulnerable state. Choice C, giving the client choices of activities, may add unnecessary pressure and decision-making burden on the client. Overall, spending time sitting with the client is the most appropriate and therapeutic nursing approach in this scenario.