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A nurse is planning care for a client who has a history of alcohol use disorder and is experiencing withdrawal. Which of the following interventions should the nurse include in the plan?
- A. Administer disulfiram
- B. Monitor for seizures
- C. Restrict fluid intake
- D. Provide a high-protein diet
Correct Answer: B
Rationale: The correct answer is B: Monitor for seizures. During alcohol withdrawal, clients are at risk for seizures due to central nervous system hyperexcitability. Monitoring for seizures allows for prompt intervention if they occur. Administering disulfiram (A) is used to deter alcohol consumption, not for withdrawal. Restricting fluid intake (C) can worsen dehydration, while providing a high-protein diet (D) is not a priority during alcohol withdrawal.
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A nurse in a mental health facility is caring for a client who has borderline personality disorder. Which of the following should the nurse expect?
- A. Self-mutilation
- B. Pacing back and forth
- C. Preoccupation with details
- D. Disorganized speech
Correct Answer: A
Rationale: The correct answer is A: Self-mutilation. Individuals with borderline personality disorder often engage in self-harming behaviors as a way to cope with intense emotions or distress. This behavior is a common manifestation of the disorder and requires careful monitoring and intervention by the nurse.
Incorrect Choices:
B: Pacing back and forth - This behavior is more commonly associated with anxiety or agitation rather than specifically with borderline personality disorder.
C: Preoccupation with details - While individuals with borderline personality disorder may display perfectionistic tendencies, preoccupation with details is not a defining characteristic of the disorder.
D: Disorganized speech - Disorganized speech is more commonly seen in conditions such as schizophrenia, rather than borderline personality disorder.
A nurse is evaluating the medication response of a client who takes naltrexone for the treatment of alcohol use disorder. The nurse should identify that which of the following is a therapeutic effect of this medication.
- A. Blocks aldehyde dehydrogenase
- B. Prevents the anxiety of abstinence
- C. Reduces substance craving
- D. Decreases the likelihood of seizures
Correct Answer: C
Rationale: The correct answer is C: Reduces substance craving. Naltrexone is an opioid receptor antagonist that helps reduce the craving for alcohol by blocking the euphoric effects associated with alcohol consumption. This medication does not block aldehyde dehydrogenase (choice A), which is involved in alcohol metabolism. It also does not prevent the anxiety of abstinence (choice B) or decrease the likelihood of seizures (choice D). Naltrexone specifically targets reducing the desire to drink, making choice C the most appropriate therapeutic effect in this scenario.
A nurse is planning care for a 3-year-old child who has autism spectrum disorder. Which of the following findings should the nurse expect?
- A. Readily initiates conversation
- B. Enjoys imaginative play
- C. Strong relationship with sibling and peers
- D. Attachment to objects that spin
Correct Answer: D
Rationale: The correct answer is D: Attachment to objects that spin. Children with autism spectrum disorder often exhibit repetitive behaviors, such as spinning objects, as a way to self-soothe or seek sensory stimulation. This behavior can serve as a coping mechanism and provide a sense of control for the child. Other choices are incorrect because children with autism spectrum disorder may have challenges in initiating conversations (A), engaging in imaginative play (B), or forming strong relationships with siblings and peers (C). By understanding the characteristics of autism spectrum disorder, the nurse can better tailor care and interventions to support the child's unique needs.
A nurse is assessing a client who is withdrawing from heroin. Which of the following manifestations should the nurse expect?
- A. Slurred speech
- B. Hypotension
- C. Bradycardia
- D. Hyperthermia
Correct Answer: D
Rationale: The correct answer is D: Hyperthermia. Heroin withdrawal can lead to hyperthermia due to increased metabolic activity, dehydration, and dysregulation of the body's temperature control mechanisms. Slurred speech (A) is not a typical manifestation of heroin withdrawal. Hypotension (B) and bradycardia (C) are more commonly associated with opioid overdose rather than withdrawal. In withdrawal, the client may actually experience hypertension and tachycardia due to increased sympathetic activity.
A nurse is teaching a client who has schizophrenia about the adverse effects of clozapine. Which of the following side effects should the nurse include in the teaching?
- A. Increased salivation
- B. Tardive dyskinesia
- C. Hypertension
- D. Photosensitivity
Correct Answer: B
Rationale: The correct answer is B: Tardive dyskinesia. Clozapine can lead to this side effect, which is characterized by involuntary movements of the face and body. This is important to include in teaching as it can be a serious and potentially irreversible effect of the medication. Increased salivation (choice A) is not a common side effect of clozapine. Hypertension (choice C) is not typically associated with clozapine use. Photosensitivity (choice D) is not a common side effect of clozapine. Overall, choice B is the correct answer as it aligns with the known side effects of clozapine in individuals with schizophrenia.