Nokea
A nurse is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse include in the discussion as a health risk of heroin use?
- A. Acute pancreatitis
- B. Slowed breathing
- C. Nasal septum perforation
- D. Permanent short-term memory loss
Correct Answer: B
Rationale: Heroin depresses the central nervous system, leading to respiratory depression.
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A nurse is caring for a client who has schizophrenia and tells the nurse, "They lie about me all the time, and they are trying to poison my food." Which of the following statements should the nurse make?
- A. "You are mistaken. Nobody is lying about you or trying to poison you."
- B. "You seem to be having very frightening thoughts."
- C. "Why do you think you are being lied about and poisoned?"
- D. "Who is lying about you and trying to poison you?"
Correct Answer: B
Rationale: The correct answer is B: "You seem to be having very frightening thoughts." This response acknowledges the client's feelings without denying or confirming the delusions. It shows empathy and validates the client's experience without reinforcing the delusions. Option A is incorrect as it denies the client's beliefs, which can lead to distrust. Option C may encourage the client to provide more details about the delusions. Option D may inadvertently validate the delusions by asking for specific details.
A nurse is teaching a newly-admitted client about the possible physical effects of alcohol withdrawal. Which of the following manifestations should the nurse include in the teaching? (Select all that apply.)
- A. Seizures
- B. Illusions
- C. Tremors
- D. Polyphagia
- E. Nystagmus
Correct Answer: A, B, C
Rationale: Answer: A, B, C are correct.
Rationale:
A: Seizures can occur during alcohol withdrawal due to CNS hyperexcitability.
B: Illusions are common manifestations due to altered sensory perception.
C: Tremors are a classic sign of alcohol withdrawal due to CNS hyperactivity.
Summary:
D: Polyphagia (excessive hunger) is not a typical physical effect of alcohol withdrawal.
E: Nystagmus (involuntary eye movements) is not commonly associated with alcohol withdrawal.
A nurse is counseling a client for the management of anxiety. The client is consistently late for appointments and ignores household chores. The client states, "I'm just too stressed. I need someone to take care of me.” The nurse identifies this behavior as an example of which of the following defense mechanisms?
- A. Dissociation
- B. Introjection
- C. Regression
- D. Repression
Correct Answer: C
Rationale: The correct answer is C: Regression. Regression is a defense mechanism where an individual reverts to an earlier stage of development when faced with stressful situations. In this scenario, the client's behavior of being consistently late and avoiding responsibilities reflects a regression to a state where they feel the need to be taken care of, like a child seeking comfort from a caregiver. This behavior is a way of coping with anxiety by seeking refuge in a familiar and less demanding role. Dissociation (A) involves disconnecting from reality to avoid distress, introjection (B) is internalizing the qualities of others, and repression (D) is unconsciously suppressing unwanted thoughts or memories.
A nurse is assessing a client who has schizophrenia. The client says, "I hear voices telling me what to do." This is an example of which of the following?
- A. Delusional disorder
- B. Associative looseness
- C. Hallucination
- D. Anhedonia
Correct Answer: C
Rationale: Auditory hallucinations are common in schizophrenia, involving hearing voices that are not real.
A nurse is speaking with the parents of a 4-year-old child who has a terminal illness. The parents tell the nurse they have taken their son's name off the list for little league baseball next season. Which of the following responses should the nurse make?
- A. It must be frustrating for you to have to cancel an activity your son enjoyed.'
- B. Baseball can be a dangerous sport for children anyway.'
- C. You never know. He could be ready for baseball by the spring.'
- D. Why did you feel you needed to do that at this time?'
Correct Answer: A
Rationale: The correct answer is A: "It must be frustrating for you to have to cancel an activity your son enjoyed." This response shows empathy and acknowledges the parents' feelings without judgment. It validates their emotions and demonstrates understanding of their situation. Choice B is incorrect because it is dismissive and irrelevant to the parents' emotional state. Choice C is incorrect as it minimizes the parents' decision and disregards their current feelings. Choice D is incorrect as it may come off as confrontational and not empathetic towards the parents' emotions. The key is to show empathy and understanding towards the parents' situation, making choice A the most appropriate response.