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A nurse is reviewing the medical record of a client who is to receive electroconvulsive therapy. The nurse should notify the provider for which of the following findings?
- A. Asthma.
- B. Crohn's disease.
- C. Renal colic.
- D. Cardiac arrhythmia.
Correct Answer: D
Rationale: Cardiac arrhythmia is a contraindication for ECT because the procedure can increase the risk of cardiac complications. ECT involves electrical stimulation that can affect heart rhythm, requiring prior cardiac evaluation.
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A nurse is collecting data for a health history from a client who has antisocial personality disorder. Which of the following clinical findings is associated with this disorder?
- A. Withdrawn behaviors.
- B. Blunted affect.
- C. Excessively anxious.
- D. Exploitive of others.
Correct Answer: D
Rationale: Exploitive of others is a key characteristic of antisocial personality disorder. Individuals often disregard others’ rights and manipulate them for personal gain, aligning with the disorder’s profile.
A nurse is assisting with reminiscence therapy for a group of older adult clients. Which of the following strategies should the nurse implement?
- A. Making a unit calendar to promote orientation.
- B. Discussing childhood memories during group therapy.
- C. Encouraging thought-stopping to block undesirable thoughts.
- D. Playing board games with other clients to enhance cognition.
Correct Answer: B
Rationale: Discussing childhood memories fosters reminiscence, aiding in cognitive stimulation and emotional connection among older adults. This aligns with the goals of reminiscence therapy, unlike orientation aids or thought-stopping.
A nurse is caring for a client who has an opioid use disorder. The nurse should anticipate that the provider will prescribe which of the following medications for treatment?
- A. Phenobarbital.
- B. Diazepam.
- C. Chlordiazepoxide.
- D. Buprenorphine.
Correct Answer: D
Rationale: Buprenorphine is a partial opioid agonist used in medication-assisted treatment for opioid use disorder, helping to reduce cravings and withdrawal symptoms. It’s specifically indicated for this condition.
Nurses' Notes
0205: Client brought to the ED by police after being found wandering on the street. Client able to provide identity to police but not able to identify place or time. Family notified. Client confused and agitated. Appearance is disheveled. Mucous membranes dry. Lungs clear and equal, heart rhythm regular. During data collection, client states, "Can you ask that person to leave my room?" Client is pointing to an empty chair.
0415: Client's adult child arrived to the ED and went to client's room. Client identified family member. Client is pacing and agitated, and states, "I don't understand why I am here." Adult child asks nurse to talk outside of room and states, "I don't know why they are so confused. They are not normally like this." Adult child states client has past medical history of hypertension and alcohol-related cirrhosis. Upon returning to room, client voided 250 mL of dark yellow, cloudy urine.
Vital Signs
0200:
• Temperature: 38.6°C (101.5°F)
• Heart rate: 104/min
• Respiratory rate: 18/min
• Blood pressure: 158/96 mm Hg
• Oxygen saturation: 98% on room air
0415:
• Temperature: 38.6°C (101.5°F)
• Heart rate: 108/min
• Respiratory rate: 20/min
• Blood pressure: 148/94 mm Hg
• Oxygen saturation: 98% on room air
Provider's Note
0230: Client diagnosis: delirium secondary to a urinary tract infection and dehydration. Will transfer client to medical-surgical unit.
Laboratory Results
0230:
• Serum toxicology screen: Alcohol: 60 mg/dL (80 to 200 mg/dL mild to moderate intoxication)
A nurse is caring for a 65-year-old male client in the emergency department (ED).For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.
- A. Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion.
- B. Administer lorazepam.
- C. Initiate 1:1 supervision.
- D. Administer acyclovir.
Correct Answer: A,B,C
Rationale: IV fluids address dehydration, lorazepam manages agitation or withdrawal, and 1:1 supervision ensures safety due to delirium. Acyclovir is unexpected as no viral infection is indicated.
A nurse in a substance use disorder clinic is explaining the alcohol recovery process to a client's family. Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder?
- A. Form a close support network.
- B. Acknowledge an inability to control drinking.
- C. Incorporate a form of spirituality into daily life.
- D. Agree to a prescription for an alcohol use deterrent.
Correct Answer: B
Rationale: Acknowledging an inability to control drinking is crucial as it represents acceptance of the problem. Without this self-awareness, the individual is unlikely to seek or benefit from treatment options. This step is foundational, preceding the use of support networks, spirituality, or medication.