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A nurse is reinforcing teaching about alcohol tolerance with a newly admitted client. Which of the following statements by the client indicates understanding?
- A. Alcohol tolerance produces physical changes when I haven't recently ingested alcohol.'
- B. Alcohol tolerance causes me to have an increased effect when taking opiates.'
- C. I will develop a decreased physical response to alcohol.'
- D. Alcohol tolerance is a medical emergency and can develop as a result of withdrawal.'
Correct Answer: C
Rationale: The correct answer is C: "I will develop a decreased physical response to alcohol." This statement indicates understanding of alcohol tolerance, where the body becomes less responsive to the effects of alcohol over time, requiring larger amounts to achieve the same effect. Choice A is incorrect as alcohol tolerance actually leads to a decreased response, not physical changes when alcohol is not consumed. Choice B is incorrect as alcohol tolerance does not affect the response to opiates. Choice D is incorrect as alcohol tolerance is not a medical emergency; it is a gradual adaptation to alcohol consumption.
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A nurse is teaching a newly licensed nurse about appropriate actions to take when a client threatens to harm a specific individual. Which of the following statements by the newly licensed nurse indicates understanding?
- A. "I need to make sure that the potential victim is warned."
- B. "I need to keep the information confidential due to the client's right to privacy."
- C. "I can only discuss the client’s threats with a court order."
- D. "I should verbally report this information to the psychiatrist."
Correct Answer: A
Rationale: The correct answer is A. When a client threatens harm to a specific individual, the appropriate action is to ensure the safety of the potential victim by warning them. This is crucial in preventing harm and fulfilling the nurse's duty to protect life. Option B is incorrect because in cases of potential harm, confidentiality can be breached to protect others. Option C is incorrect as waiting for a court order delays necessary action. Option D is incorrect as immediate action should be taken rather than waiting for a psychiatrist's involvement.
A nurse is speaking with a client experiencing anxiety. Which of the following responses is most therapeutic?
- A. "Most clients with anxiety benefit from lying down."
- B. "Come with me to an area where we can talk without interruption."
- C. "Providers usually recommend relaxation exercises for clients who are upset."
- D. "An antianxiety pill works best for situations like this."
Correct Answer: B
Rationale: The correct answer is B. Bringing the client to an area for uninterrupted conversation shows active listening and support. It promotes a safe space for the client to express feelings and reduces anxiety. Choice A is incorrect as it assumes all clients benefit from lying down, which may not be true. Choice C is incorrect because recommending relaxation exercises may not address the client's immediate needs. Choice D is incorrect as medication should not be the first response for managing anxiety without exploring other options first.
A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania?
- A. The client's spouse reports that the client has recently gained weight.
- B. The client is dressed in all black.
- C. The client responds to questions with disorganized speech.
- D. The client reports that voices are telling him to write a novel.
Correct Answer: C
Rationale: The correct answer is C because disorganized speech is a key symptom of acute mania in bipolar disorder. Disorganized speech is characterized by incoherent, rapid, and tangential responses, reflecting the racing thoughts and pressured speech commonly seen in manic episodes. This symptom is indicative of a manic state, which is a defining feature of bipolar disorder. Choices A, B, and D are incorrect because they do not directly relate to the diagnostic criteria for acute mania. Weight gain, clothing color choice, and auditory hallucinations are not specific to mania and could be present in other mental health conditions.
A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client’s head is down, and he is wringing his hands. Which of the following actions should the nurse take?
- A. Encourage the client to go back to bed.
- B. Give the client a PRN sleeping medication.
- C. Remain with the client.
- D. Explore alternatives to pacing the floor with the client.
Correct Answer: C
Rationale: The correct answer is C: Remain with the client. By remaining with the client, the nurse can provide support and reassurance, assess the client's emotional state, and ensure the client's safety. This action shows empathy and promotes therapeutic communication. Encouraging the client to go back to bed (A) may not address the underlying issue causing the restlessness. Giving a PRN sleeping medication (B) without further assessment may not be appropriate and could mask the client's feelings. Exploring alternatives to pacing (D) is a good intervention but should come after providing immediate support and understanding the client's needs.
A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings should the nurse expect?
- A. Hand tremors
- B. Stuporous level of consciousness
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: The correct answer is A: Hand tremors. During acute alcohol withdrawal, the central nervous system is hyperexcitable due to the sudden absence of alcohol. This can lead to symptoms such as hand tremors, anxiety, agitation, and even seizures. Stuporous level of consciousness (choice B) is not expected in alcohol withdrawal, as clients typically exhibit hyperactivity. Bradycardia (choice C) and hypotension (choice D) are unlikely findings, as alcohol withdrawal commonly causes increased heart rate and blood pressure due to sympathetic nervous system activation.