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A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?
- A. "I check any room I enter because the enemy is still after me and could be hiding anywhere."
- B. "I killed four enemy soldiers with my bare hands and saved my entire battalion."
- C. "My child was born with a birth defect due to an exposure I had overseas."
- D. "In my dreams, all I can see are the wounded reaching out and trying to grab me."
Correct Answer: D
Rationale: The correct answer is D because the statement indicates the client is experiencing intrusive memories and nightmares, which are common symptoms of PTSD. This suggests the client is reliving the traumatic event. Choice A suggests hypervigilance, which can be a symptom of PTSD but is not as specific as intrusive memories. Choice B indicates possible grandiosity or exaggerated sense of self-importance. Choice C suggests guilt related to a different issue. Summarily, choices A, B, and C do not directly align with the hallmark symptoms of PTSD like choice D does.
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A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity?
- A. The client runs 4 miles outdoors every afternoon.
- B. The client drinks 2 liters of liquids daily.
- C. The client eats 2-3 grams of sodium-containing foods daily.
- D. The client eats foods high in tyramine.
Correct Answer: A
Rationale: The correct answer is A. Running 4 miles daily causes excessive sweating, leading to dehydration and potential lithium toxicity. Lithium is excreted through the kidneys and dehydration can decrease kidney function, causing lithium levels to rise. Choices B and C are actually helpful as adequate hydration and normal sodium intake reduce the risk of lithium toxicity. Choice D is irrelevant as tyramine is not linked to lithium toxicity.
A nurse is providing teaching about confidentiality with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
- A. "The courts might require me to discuss confidential information."
- B. "I am required to provide confidential information to insurance companies."
- C. "If questioned during a police investigation, I am required to divulge confidential information."
- D. "I am legally allowed to discuss confidential information with the client's former therapist."
Correct Answer: A
Rationale: Confidentiality may be broken if required by law, such as with a court order.
A nurse is caring for a client who has bipolar disorder and is running around the unit asking people to dance with her. Which of the following interventions should the nurse take?
- A. Turn on a dance video so the client can burn off excess energy.
- B. Offer the client a low-calorie snack in return for stopping the behavior.
- C. Walk the client outside and sit with her in the garden area.
- D. Observe the client closely for the development of aggressive behavior.
Correct Answer: C
Rationale: The correct answer is C: Walk the client outside and sit with her in the garden area. This intervention helps the client to redirect their energy in a positive and calming manner. Being outdoors can provide a change of environment, fresh air, and can help the client feel more grounded. It also offers a distraction from the impulsive behavior and promotes relaxation. Turning on a dance video (choice A) may further stimulate the client's behavior rather than calming them down. Offering a snack (choice B) may reinforce the behavior and is not addressing the underlying issue. Observing for aggressive behavior (choice D) is important but does not actively address the client's current behavior.
A nurse is caring for a client who has a history of alcohol use disorder and has been hospitalized for detoxification. The nurse enters the room and finds the client shouting in a terrified voice, "Get these bugs off of me!” Which of the following responses by the nurse is appropriate?
- A. "I'm sure that the bugs you see will not harm you."
- B. "Tell me more about the bugs that you see in your room."
- C. "I don't see any bugs, but you seem very frightened."
- D. "I do not see anything. This is part of the withdrawal process."
Correct Answer: C
Rationale: Response C is appropriate because it acknowledges the client's feelings without confirming the presence of bugs. This response shows empathy and understanding while not reinforcing the client's hallucination. Response A dismisses the client's fear and may increase anxiety. Response B encourages the client to focus on the hallucination, worsening the distress. Response D invalidates the client's experience and may lead to distrust.
A nurse is discussing the manifestations of alcohol withdrawal with a client who has a history of alcohol use disorder. Which of the following client statements indicates understanding?
- A. "I should expect tremors to start less than 24 hours after I stop drinking."
- B. "Disulfiram will block my cravings for alcohol."
- C. "My symptoms should last about 5 to 7 days once they begin."
- D. "It is important that I take vitamin C to prevent cirrhosis or other liver damage."
Correct Answer: A
Rationale: The correct answer is A because alcohol withdrawal symptoms, including tremors, typically begin within 6-24 hours after the last drink. This statement shows an accurate understanding of the timing of alcohol withdrawal manifestations. Choice B is incorrect because Disulfiram is a medication used to deter alcohol consumption, not block cravings. Choice C is incorrect because alcohol withdrawal symptoms can last beyond 5-7 days. Choice D is incorrect because vitamin C does not prevent cirrhosis or liver damage from alcohol abuse.