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A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?
- A. Keep a journal of how often you check the locks each night
- B. Snap a rubber band on your wrist when you think about checking the locks
- C. Ask a family member to check the lock for you at night
- D. Focus on abdominal breathing whenever you go to check the locks
Correct Answer: B
Rationale: The correct answer is B: Snap a rubber band on your wrist when you think about checking the locks. This is an effective use of thought stopping technique as it creates a physical distraction and discomfort when the client has obsessive thoughts. It helps interrupt the pattern of behavior and redirects the client's focus away from the compulsion. Keeping a journal (A) may increase anxiety and reinforce the behavior. Asking a family member to check the lock (C) doesn't address the client's need to manage their own thoughts and behaviors. Focusing on abdominal breathing (D) may be a relaxation technique but doesn't directly address the obsessive thoughts.
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A nurse is caring for a client who has a lithium level of 0.8 mEq/L. Which of the following actions should the nurse take?
- A. Withhold the next dose of lithium
- B. Repeat the lithium level test
- C. Administer the next dose of lithium
- D. Recommend a low sodium diet
Correct Answer: C
Rationale: The correct answer is C: Administer the next dose of lithium. A lithium level of 0.8 mEq/L is within the therapeutic range (0.6-1.2 mEq/L), so the nurse should continue the medication as prescribed. Withholding the dose (choice A) can lead to subtherapeutic levels and ineffective treatment. Repeating the test (choice B) is unnecessary as the current level is within the therapeutic range. Recommending a low sodium diet (choice D) is not directly related to lithium therapy.
A nurse is assessing a child in the emergency department. Which of the following findings places the child at the greatest risk for physical abuse?
- A. The child is 10 years old
- B. The child is home-schooled
- C. The child has no siblings
- D. The child has cystic fibrosis
Correct Answer: A
Rationale: The correct answer is A: The child is 10 years old. Children between 8-12 years old are at higher risk for physical abuse due to increased independence and potential conflicts with caregivers. Being 10 years old puts the child at a critical age for abuse. Choice B (home-schooled) does not directly correlate with an increased risk of abuse. Choice C (no siblings) does not indicate abuse risk. Choice D (cystic fibrosis) is a medical condition and does not specifically increase the risk of physical abuse.
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.
A nurse is assessing a client who is experiencing alcohol withdrawal. For which of the following findings should the nurse anticipate administration of lorazepam?
- A. Bradycardia
- B. Stupor
- C. Afebrile
- D. Hypertension
Correct Answer: D
Rationale: The correct answer is D: Hypertension. Lorazepam is a benzodiazepine commonly used to manage alcohol withdrawal symptoms, including hypertension. Alcohol withdrawal often leads to increased sympathetic nervous system activity, causing elevated blood pressure. Lorazepam helps to reduce this symptom by promoting relaxation and reducing anxiety. Bradycardia (A), stupor (B), and afebrile (C) are not indications for lorazepam administration in alcohol withdrawal. Bradycardia and stupor may require further evaluation for potential complications, while afebrile state does not directly warrant lorazepam use.
A nurse is providing teaching to a client who has panic disorder and is receiving alprazolam. Which of the following instructions should the nurse include?
- A. Take the medication on an empty stomach
- B. Avoid activities that require alertness
- C. Stop taking the medication if dizziness occurs
- D. Take an additional dose if anxiety increases
Correct Answer: B
Rationale: The correct answer is B: Avoid activities that require alertness. This is important because alprazolam is a benzodiazepine that can cause drowsiness and impair cognitive function. By avoiding activities that require alertness, the client can prevent accidents or injuries.
A: Taking the medication on an empty stomach is not necessary for alprazolam.
C: Stopping the medication if dizziness occurs is not recommended without consulting a healthcare provider.
D: Taking an additional dose if anxiety increases can lead to overdose and is not safe.
Therefore, choice B is the most appropriate instruction to include in teaching the client with panic disorder taking alprazolam.