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A nurse is providing teaching to a client who has alcohol use disorder about Alcoholics Anonymous (AA). Which of the following client statements indicates an understanding of the program's basic concepts?
- A. "I am responsible for my alcoholism."
- B. "I need to identify things that cause me to be an alcoholic."
- C. "I am powerless against my addiction to alcohol."
- D. "I need to see a counselor who will be responsible for my recovery."
Correct Answer: C
Rationale: AA is based on the principle of acknowledging powerlessness over addiction and seeking support.
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A nurse caring for a client who has depression observes the client comes to breakfast freshly bathed, wearing clean clothes, and with combed and styled hair. Which of the following responses by the nurse is therapeutic?
- A. "Everyone feels better after showering."
- B. "You must be getting better. You look great!"
- C. "I see you have done some grooming today."
- D. "Why are you all dressed up today? Is it a special occasion?"
Correct Answer: C
Rationale: A neutral, observational statement acknowledges the client’s effort without assuming improvement.
A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?
- A. Experiencing diarrhea
- B. Exercising moderately
- C. Increasing sodium intake
- D. Drinking green tea
Correct Answer: A
Rationale: The correct answer is A: Experiencing diarrhea. Diarrhea can lead to dehydration and electrolyte imbalances, which can increase lithium levels in the blood and cause toxicity. This is because lithium is primarily excreted by the kidneys, and dehydration can impair its elimination. Options B, C, and D are incorrect because moderate exercise, increasing sodium intake, and drinking green tea are not known to directly cause lithium toxicity. In fact, maintaining adequate hydration and a balanced diet with normal sodium intake can help prevent lithium toxicity.
A nurse is caring for a client who has cancer and is scheduled for immediate chemotherapy. The client tells the nurse that she wants to try nontraditional treatments first. Which of the following responses should the nurse make?
- A. "Using nontraditional treatments is not a good idea. I'd rather you avoid that route."
- B. "Your provider is very knowledgeable. If he prescribes chemotherapy, it's the best treatment for you."
- C. "A lot of people think nontraditional treatments will work, and they find out too late that they made the wrong choice."
- D. "Tell me more about your concerns about taking chemotherapy."
Correct Answer: D
Rationale: Exploring the client’s concerns helps build trust and encourages shared decision-making.
A nurse is assessing an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect?
- A. Tachycardia
- B. Constipation
- C. Menorrhagia
- D. Hyperkalemia
Correct Answer: B
Rationale: The correct answer is B: Constipation. In anorexia nervosa, a lack of adequate nutrition intake can lead to decreased gastrointestinal motility, resulting in constipation. Tachycardia (A) is common due to the body's response to malnutrition. Menorrhagia (C) is unlikely as anorexia nervosa often leads to amenorrhea. Hyperkalemia (D) is less likely as potassium levels tend to be low due to decreased food intake.
A nurse is caring for a client who has bipolar disorder and a new prescription for valproate. Which of the following instructions should the nurse give the client about the use of this medication?
- A. Thyroid function tests should be performed every 6 months.
- B. A pretreatment electroencephalogram (EEG) will be done.
- C. Liver function tests should be monitored.
- D. High serum sodium levels can cause toxic levels of valproate.
Correct Answer: C
Rationale: Valproate is metabolized in the liver, requiring regular liver function monitoring.