Nokea
The client is dependent on nicotine and wishes to discontinue smoking.
A nurse is reinforcing teaching with a client who is dependent on nicotine and wishes to discontinue smoking. The nurse should inform the client that which of the following is a manifestation of nicotine withdrawal?
- A. Weight loss
- B. Diaphoresis
- C. Insomnia
- D. Diarrhea
Correct Answer: C
Rationale: Insomnia is a common nicotine withdrawal symptom.
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The client becomes combative and threatens other clients and staff.
A nurse is working with a client who becomes combative and threatens other clients and staff. Which of the following actions should the nurse take?
- A. Stand in front of the client to block them from others in the room.
- B. Apply restraints according to the facility's standing order.
- C. Ensure there are enough staff members available for assistance.
- D. Obtain a PRN prescription for restraints from the provider.
Correct Answer: C
Rationale: Ensuring staff availability ensures safety without immediate restraint use.
The client reports he has headaches after taking chewable isosorbide dinitrate.
A nurse is caring for a client who reports he has headaches after taking chewable isosorbide dinitrate. Which of the following statements should the nurse make?
- A. Swallow the tablet whole to minimize your headaches.
- B. You can discontinue the medication until the headache goes away.
- C. You should take the medication on an empty stomach to prevent a headache.
- D. The headaches should decrease as you get used to the medication.
Correct Answer: D
Rationale: Headaches are a common side effect of isosorbide that typically lessen over time.
The client consumed alcohol 2 days after taking disulfiram.
A nurse is caring for a client who consumed alcohol 2 days after taking disulfiram. The nurse should monitor the client for which of the following findings?
- A. Constipation
- B. Dry skin
- C. Hypotension
- D. Urinary retention
Correct Answer: C
Rationale: Disulfiram-alcohol reaction causes hypotension among other symptoms.
The client is expressing suicidal ideations.
A nurse is collecting data from a client who is expressing suicidal ideations. Which of the following questions is the nurse's priority?
- A. Do you have a plan for harming yourself?
- B. Has anyone in your family ever died by suicide?
- C. Do you have someone to discuss your feelings with?
- D. Can you tell me about the stresses in your life?
Correct Answer: A
Rationale: Assessing a plan determines immediate risk, the priority in suicide assessment.
The client is taking multiple medications and asks about possible interactions.
A nurse is caring for a client who is taking multiple medications and asks about possible interactions. To which of the following members of the interdisciplinary team should the nurse make a referral?
- A. Social worker
- B. Advanced practice nurse
- C. Patient care technician
- D. Psychologist
Correct Answer: B
Rationale: An advanced practice nurse can expertly assess medication interactions.