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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 discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements by a staff member indicates an understanding of the teaching?
- A. "The legal requirement for client confidentiality ceases if the client is deceased."
- B. "Staff members are required to divulge information to attorneys if they call for information."
- C. "Health care workers are not required to answer a court's requests for information about a client's disclosure."
- D. "Providers are required to warn individuals if the client threatens harm."
Correct Answer: D
Rationale: The correct answer is D because it refers to the duty to warn, which is a legal exception to client confidentiality. When a client poses a serious and imminent threat of harm to others, healthcare providers have a duty to warn those at risk. This exception prioritizes public safety over confidentiality.
Explanation of why other choices are incorrect:
A: Incorrect. Confidentiality typically extends even after a client's death to protect their privacy rights and maintain trust in healthcare providers.
B: Incorrect. Disclosing information to attorneys without client consent violates confidentiality unless required by law or court order.
C: Incorrect. Healthcare workers are generally required to comply with court requests for information unless protected by a legal privilege.
E, F, G: Not provided.
A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for staff following this incident?
- A. Provide professional counseling for staff members.
- B. Change policies for staff observation of clients who are suicidal.
- C. Identify cues in the client's behavior that might have warned them that he was contemplating suicide.
- D. Give the family an opportunity to talk about their feelings.
Correct Answer: C
Rationale: The correct answer is C: Identify cues in the client's behavior that might have warned them that he was contemplating suicide. This is the priority intervention because understanding the warning signs can help prevent future suicides by recognizing and addressing high-risk behaviors. Providing counseling (A) is important but not the immediate priority. Changing policies (B) may be necessary in the long term but does not address the current situation. Giving the family an opportunity to talk (D) is important for support but does not directly address staff intervention.
A nurse is reviewing medication records for several psychiatric clients who have bipolar disorder. Which of the following medications is commonly used to treat bipolar disorder?
- A. Paroxetine
- B. Lithium
- C. Donepezil
- D. Valproate
- E. Carbamazepine
Correct Answer: B
Rationale: The correct answer is B: Lithium. Lithium is a mood stabilizer commonly used to treat bipolar disorder by reducing the frequency and intensity of manic episodes. It helps to balance neurotransmitters in the brain. Paroxetine (A) is an antidepressant, Donepezil (C) is used for Alzheimer's disease, Valproate (D) is another mood stabilizer, and Carbamazepine (E) is an anticonvulsant often used in bipolar disorder. Therefore, the correct choice is Lithium (B) as it specifically targets bipolar symptoms.
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.
A nurse is caring for a client who has schizophrenia and is experiencing a hallucination. Which of the following actions should the nurse take?
- A. Act as if the hallucination is real.
- B. Instruct the client to argue with the voices that are a part of the hallucination.
- C. Ask the client direct questions about the hallucination.
- D. Tell the client that the hallucination is not a part of reality.
Correct Answer: C
Rationale: The correct answer is C - Ask the client direct questions about the hallucination. This approach helps the nurse understand the client's experience without validating or denying the hallucination. It shows empathy and promotes trust. Choice A would validate the hallucination, worsening the client's condition. Choice B could escalate the situation by encouraging confrontation with the voices. Choice D may cause the client to feel dismissed or judged. Asking direct questions (C) allows the nurse to gather information, assess the client's safety, and provide appropriate care.