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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.
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A nurse in a mental health facility is interacting with a client who is angry and becoming increasingly aggressive. Which of the following actions should the nurse take?
- A. Move the client to a private area so the conversation will not be disturbed.
- B. Use clarification to determine what the client is feeling.
- C. Speak to the client using an authoritative voice.
- D. Maintain constant eye contact with the client.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Moving the client to a private area ensures privacy, reduces stimulation, and promotes a sense of safety, which can help de-escalate the situation. It also prevents the client from feeling embarrassed or judged by others, allowing for more open communication. This approach prioritizes the client's emotional well-being and safety.
Summary:
B: While clarification is important for understanding the client's emotions, it may not be the most immediate action needed in a potentially escalating situation.
C: Speaking authoritatively may further agitate the client and escalate the situation.
D: Maintaining constant eye contact could be perceived as confrontational and may escalate aggression.
A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?
- A. Prepare for gastric lavage due to an extremely elevated lithium level.
- B. Administer the morning dose of lithium.
- C. Check the client's medication record to assess whether the client has been refusing her lithium.
- D. Hold the medication and assess for early manifestations of toxicity.
Correct Answer: B
Rationale: A lithium level of 1.0 mEq/L is within the therapeutic range (0.6-1.2 mEq/L).
A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?
- A. Rotate assignment of daily caregivers.
- B. Provide an activity schedule that changes from day to day.
- C. Limit time for the client to perform activities.
- D. Talk the client through tasks one step at a time.
Correct Answer: D
Rationale: Clients with Alzheimer's benefit from structured routines and step-by-step guidance.
A nurse in an emergency department is assessing a client for suspected cocaine intoxication. Which of the following findings should the nurse expect?
- A. Nystagmus
- B. Dilated pupils
- C. Hypersomnia
- D. Depression
Correct Answer: B
Rationale: The correct answer is B: Dilated pupils. Cocaine intoxication typically presents with dilated pupils due to the drug's stimulant effects on the sympathetic nervous system. This causes pupil dilation by increasing the release of norepinephrine. Nystagmus (choice A) is not a common finding in cocaine intoxication. Hypersomnia (choice C) is unlikely as cocaine is a stimulant that often leads to decreased need for sleep. Depression (choice D) is not a typical symptom of cocaine intoxication. In summary, dilated pupils are a key indicator of cocaine intoxication, while nystagmus, hypersomnia, and depression are not characteristic findings.
A nurse is caring for a client who is dying. The client says, "My mother died in the hospital, but I did not get there before she died." Which of the following statements should the nurse make?
- A. "We will call your family in time for them to get here."
- B. "I wonder if you are fearful of dying alone."
- C. "I will make sure a staff member is in your room at all times."
- D. "I will tell your family of your concern so that they can be here."
Correct Answer: B
Rationale: The correct answer is B: "I wonder if you are fearful of dying alone." This response shows empathy and addresses the client's emotional needs. It acknowledges the client's fear and opens up a conversation about their concerns. It allows the client to express their feelings and provides an opportunity for therapeutic communication.
Choice A is incorrect because it only focuses on calling the family and does not address the client's emotional state. Choice C is incorrect as it only ensures physical presence but does not address the client's emotional needs. Choice D is incorrect as it shifts the responsibility to the family without acknowledging the client's feelings.