Nokea
A nurse is preparing to administer lorazepam to a patient with acute anxiety. Which intervention is most important for the nurse to consider?
- A. Monitor for signs of excessive sedation.
- B. Ensure the patient is hydrated before administration.
- C. Administer the medication only after meals.
- D. Monitor the patient for signs of depression.
Correct Answer: A
Rationale: Lorazepam is a benzodiazepine that can cause sedation and respiratory depression. The nurse must monitor the patient closely to ensure they are not excessively sedated.
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A nurse is assessing a patient diagnosed with major depressive disorder. The patient states, 'I feel like everything is falling apart, and I can't keep up anymore.' Which nursing diagnosis is most appropriate for this patient?
- A. Impaired social interaction
- B. Risk for suicide
- C. Ineffective coping
- D. Hopelessness
Correct Answer: D
Rationale: The patient's statement reflects feelings of hopelessness, which is a common symptom in major depressive disorder and often leads to a sense of despair.
The unit secretary receives a phone call from the health insurer for a hospitalized patient. The caller seeks information about the patients projected length of stay. How should the nurse instruct the unit secretary to handle the request?
- A. Obtain the information from the patients medical record and relay it to the caller.
- B. Inform the caller that all information about patients is confidential.
- C. Refer the request for information to the patients case manager.
- D. Refer the request to the health care provider.
Correct Answer: C
Rationale: The case manager usually confers with insurers and provides the treatment team with information about available resources. The unit secretary should be mindful of patient confidentiality and should neither confirm that the patient is an inpatient nor disclose other information.
A client experienced the death of their grandmother six months ago. They present to the clinic today with feelings of hopelessness, sadness, not sleeping, and crying throughout the day. What does the nurse anticipate the cause of the client’s symptoms to be?
- A. Anxiety
- B. Prolonged grief
- C. Normal grieving process
- D. Emotional numbness
Correct Answer: B
Rationale: Symptoms persisting beyond six months and impairing daily functioning suggest prolonged grief rather than a normal grieving process.
A nurse is caring for a client who was hospitalized with a high blood alcohol content level. The provider fears the client may go into withdrawal and require medical supervision. The client's manifestations included anxiety, tremors, BP 166/100 mm Hg, and tachypnea about 1 hr ago. Now the client begins yelling out that they are seeing spiders crawling all over the walls. They believe they are at home and begin calling for their mother. The nurse should recognize that the client is experiencing which of the following stages of alcohol withdrawal?
- A. Stage 3 (severe)
- B. The client's manifestations indicate a psychotic disorder instead of alcohol withdrawal.
- C. Stage 2 (moderate)
- D. Stage 1 (mild)
Correct Answer: A
Rationale: Stage 3 (severe) alcohol withdrawal includes disorientation, hallucinations, and seizures. The client's symptoms, including hallucinations and confusion, are consistent with severe alcohol withdrawal.
A person tells the nurse, 'My spouse abuses me most often when intoxicated. The drinking has increased lately, but I always receive an apology afterward and a box of chocolates. I’ve considered leaving home but haven’t been able to bring myself to actually leave.' Which phase in the cycle of violence prevents the patient from leaving?
- A. Tension-building
- B. Acute battering
- C. Honeymoon
- D. Recovery
Correct Answer: C
Rationale: The honeymoon phase (Option C) features remorse (apologies, gifts), reinforcing hope and preventing departure, per Walker’s cycle of violence. Tension-building (A) escalates, battering (B) is the act, and recovery (D) is not a phase.