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 identify as the primary cause of liver cirrhosis?
- A. Alcohol
- B. Caffeine
- C. Cocaine
- D. Inhalants
Correct Answer: A
Rationale: Chronic alcohol use is the leading cause of liver cirrhosis due to its toxic effects on liver cells.
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A nurse in the emergency department is creating a plan of care for a client experiencing alcohol intoxication. Which of the following interventions should the nurse plan to include? (Select all that apply.)
- A. Contact the laboratory to obtain a blood sample.
- B. Prepare the client for a CT scan.
- C. Check the client’s pupil reactivity.
- D. Obtain a urine specimen.
- E. Perform a developmental screening test.
Correct Answer: A, B, C, D
Rationale: The correct interventions for a client experiencing alcohol intoxication are A, B, C, and D. A blood sample is crucial to assess alcohol levels. A CT scan may be needed to rule out head trauma or other underlying issues. Checking pupil reactivity can indicate neurological status. Obtaining a urine specimen helps assess kidney function and possible drug use. Choice E, performing a developmental screening test, is not relevant to the immediate care needs of an individual with alcohol intoxication.
A nurse is assessing a client who is to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make?
- A. "It's okay to feel scared. Let's talk about what you are afraid of."
- B. "Don't worry. The important thing is you have now quit smoking."
- C. "I understand your fears. I was a smoker also."
- D. "Your doctor is a great surgeon. You will be fine."
Correct Answer: A
Rationale: The correct answer is A: "It's okay to feel scared. Let's talk about what you are afraid of." This response shows empathy and acknowledges the client's feelings, which is an essential aspect of therapeutic communication. By inviting the client to talk about her fears, the nurse creates a safe space for the client to express her emotions and concerns. This can help alleviate anxiety and build trust between the client and the nurse.
Choices B, C, and D are incorrect because they do not directly address the client's emotional state or offer support. B focuses on smoking cessation, which may not be the immediate concern for the client undergoing surgery. C shifts the focus to the nurse's personal experience, which may detract from the client's needs. D dismisses the client's fears and offers reassurance without addressing the underlying emotions.
A nurse is admitting a client to an alcohol abuse program. The client states, "I'm here because of my boss. It was part of my job to go to parties and drink with clients.” The client's statement is an example of which of the following defense mechanisms?
- A. Reaction formation
- B. Compensation
- C. Rationalization
- D. Suppression
Correct Answer: C
Rationale: The correct answer is C: Rationalization. Rationalization is a defense mechanism where individuals justify their behaviors, feelings, or thoughts by providing logical reasons that may not be true. In this scenario, the client is justifying their excessive drinking by blaming it on their job requirement, which is a form of rationalization.
A: Reaction formation involves expressing the opposite of how one truly feels.
B: Compensation is making up for a deficiency in one area by excelling in another.
D: Suppression is consciously pushing unwanted thoughts or feelings out of one's mind.
A nurse is planning a unit orientation for a newly admitted client who has severe depression. Which of the following should be the nurse's approach?
- A. Sit with the client and offer simple, direct information.
- B. Have the client attend group therapy immediately.
- C. Explain the unit policies to the client and answer any questions he might have.
- D. Take the client on a tour of the unit and introduce him to all the staff members on duty.
Correct Answer: A
Rationale: Clients with severe depression may have difficulty processing large amounts of information, so simple, direct communication is best.
A nurse is assessing a client who has post-traumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?
- A. Sleeping 12 hours or more each day
- B. Increasing sense of attachment to others
- C. Constricted willingness to talk about the event
- D. Increasing feelings of anger
Correct Answer: C
Rationale: Avoidance of discussing the traumatic event is a key symptom of PTSD.