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A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include?
- A. Encourage group activities
- B. Provide frequent rest periods
- C. Offer high-calorie snacks
- D. Allow unlimited physical activity
Correct Answer: B
Rationale: The correct answer is B: Provide frequent rest periods. During manic episodes in bipolar disorder, individuals have high energy levels, reduced need for sleep, and increased activity levels. Providing frequent rest periods helps prevent exhaustion and promotes relaxation, which can help stabilize mood. Encouraging group activities (A) may exacerbate manic symptoms due to increased stimulation. Offering high-calorie snacks (C) can lead to poor dietary choices and worsen physical health. Allowing unlimited physical activity (D) can be dangerous as individuals in a manic state may engage in risky behaviors.
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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 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.
A nurse is giving a presentation about intimate partner abuse for a community group. Which of the following statements by a group member indicates understanding of the teaching?
- A. Survivors of abuse often feel guilty
- B. Abusers often have high self-esteem
- C. The honeymoon stage of violence usually gets longer over time
- D. As abuse continues, victims become more determined to be independent
Correct Answer: A
Rationale: Correct Answer: A: Survivors of abuse often feel guilty
Rationale: This statement indicates understanding of the psychological impact of intimate partner abuse. Guilt is a common emotion experienced by survivors due to manipulation and blame from the abuser. It reflects the internalized self-blame and shame that many survivors struggle with.
Summary of other choices:
B: Abusers often have high self-esteem - Incorrect. Abusers typically have low self-esteem and use abuse as a way to exert power and control.
C: The honeymoon stage of violence usually gets longer over time - Incorrect. The honeymoon phase tends to decrease over time as abuse cycles escalate.
D: As abuse continues, victims become more determined to be independent - Incorrect. Victims often experience increased isolation and dependency on the abuser.
A nurse is assessing a client who has opioid withdrawal. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Hyperthermia
- C. Insomnia
- D. Bradycardia
Correct Answer: C
Rationale: The correct answer is C: Insomnia. Opioid withdrawal often presents with symptoms like insomnia due to increased sympathetic activity. Hypotension (A) is less likely as opioids can cause hypertension. Hyperthermia (B) is not typically associated with opioid withdrawal. Bradycardia (D) is also less common, as opioid withdrawal can lead to tachycardia. Insomnia is a hallmark symptom of opioid withdrawal, making it the most appropriate choice.
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.