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A nurse is planning care for a client with acute delirium. Which of the following instructions should the nurse include in the plan?
- A. Reinforce the clients orientation with the calendar
- B. Refute the clients perception of visual hallucinations
- C. Teach the client assertive techniques
- D. Assign the client to a different caregiver each shift
Correct Answer: A
Rationale: The correct answer is A: Reinforce the client's orientation with the calendar. This is because in acute delirium, the client may experience confusion and disorientation. Using a calendar can help provide structure and aid in orientation. Choice B is incorrect as refuting hallucinations may worsen the client's agitation. Choice C is incorrect as assertive techniques are not typically used in managing acute delirium. Choice D is incorrect as consistency in caregivers is important for continuity of care in delirium management.
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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 caring for a client who has a new diagnosis of bulimia nervosa. Which of the following diagnosis procedures should the nurse anticipate the provider should describe during the medical evaluation?
- A. Chest x-ray
- B. ECG
- C. Coagulation studies
- D. Liver function test
Correct Answer: B
Rationale: The correct answer is B: ECG. A provider may order an ECG during the medical evaluation of a client with bulimia nervosa to assess for any potential cardiac complications, such as electrolyte imbalances or arrhythmias due to purging behaviors. This test helps in evaluating the overall cardiac health of the client. Chest x-ray (A) is not typically indicated in the evaluation of bulimia nervosa unless there are specific respiratory symptoms. Coagulation studies (C) are not directly related to the diagnosis of bulimia nervosa. Liver function test (D) is not a common diagnostic procedure for bulimia nervosa unless there are specific concerns about liver function due to other factors.
A nurse is providing teaching to a client who has obsessive-compulsive disorder and engages in excessive handwashing. Which of the following instructions should the nurse include?
- A. Encourage the client to stop washing hands
- B. Allow additional time for rituals
- C. Limit ritual behaviors immediately
- D. Ignore the compulsions
Correct Answer: B
Rationale: The correct answer is B: Allow additional time for rituals. This is because abruptly stopping the handwashing rituals can lead to increased anxiety and distress for the client. Allowing additional time for rituals can help the client feel more in control and gradually work towards reducing the behavior. Encouraging the client to stop washing hands (A) abruptly can be counterproductive. Limiting ritual behaviors immediately (C) can also increase anxiety. Ignoring the compulsions (D) may worsen the condition.
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 in a psychiatric unit is providing discharge teaching to a client who has major depressive disorder and a new prescription for fluoxetine. Which of the following instructions should the nurse include?
- A. Take the medication in the morning
- B. Expect improvement within 24 hours
- C. Discontinue the medication when symptoms improve
- D. Avoid foods high in tyramine
Correct Answer: A
Rationale: The correct answer is A: Take the medication in the morning. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) commonly prescribed for depression. Taking it in the morning helps prevent insomnia, a common side effect. Option B is incorrect as improvement may take weeks, not 24 hours. Option C is wrong as stopping abruptly can lead to withdrawal symptoms. Option D is irrelevant as tyramine interactions are associated with MAOIs, not SSRIs.