Nokea
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.
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A nurse is caring for several clients who have mental health disorders at an assisted-living facility. Which of the following clients should the nurse determine needs to be seen by a provider immediately?
- A. A client who is taking olanzapine and experiences dizziness when first standing up
- B. A client who is taking chlorpromazine and reports vomiting twice
- C. A client who is taking thioridazine and has daytime drowsiness
- D. A client who is taking clozapine and has flu-like manifestations
Correct Answer: D
Rationale: The correct answer is D. Clozapine is associated with a serious side effect called agranulocytosis, which can manifest as flu-like symptoms such as fever, sore throat, and malaise. Agranulocytosis is a potentially life-threatening condition that requires immediate medical attention to prevent complications. Clients taking clozapine should be monitored closely for signs of infection. Choices A, B, and C describe common side effects of antipsychotic medications that are not typically considered emergencies. For example, dizziness upon standing (A), vomiting (B), and daytime drowsiness (C) are known side effects that may not require immediate medical attention unless severe or persistent. Therefore, the client taking clozapine with flu-like manifestations (D) should be seen by a provider immediately due to the potential seriousness of agranulocytosis.
A nurse is caring for a 9-year-old boy who has a new diagnosis of diabetes mellitus and is eager to return to school and participate in social events. The mother tells the nurse she is afraid to let him take part in physical activities at school. Which of the following responses should the nurse make?
- A. "Tell me more about how you are feeling about your son's activities!"
- B. "You might want to use tutors to home-school him."
- C. "I agree. His well-being is the most important."
- D. "You sound overprotective. Let's talk about this some more."
Correct Answer: A
Rationale: The correct response is A: "Tell me more about how you are feeling about your son's activities!" This response demonstrates active listening and empathy, allowing the mother to express her concerns and fears openly. By understanding her perspective, the nurse can provide tailored education and support to address her specific worries regarding her son's activities. This approach fosters trust and collaboration between the nurse and the mother, leading to a more effective care plan for the child.
Incorrect responses:
B: "You might want to use tutors to home-school him." - This response does not address the mother's concerns directly and suggests an extreme solution without exploring the root of her fears.
C: "I agree. His well-being is the most important." - While well-being is essential, this response does not invite further discussion or address the mother's specific worries.
D: "You sound overprotective. Let's talk about this some more." - This response may come off as judgmental and dismissive of the mother's
A nurse is caring for a client who attacked one of her friends and is admitted to the psychiatric unit. Which of the following actions should the nurse take first?
- A. Establish a client relationship.
- B. Explain to the client that the behavior was unacceptable.
- C. Explore the truth of the client’s statements.
- D. Set behavioral limits for the client.
Correct Answer: D
Rationale: Setting behavioral limits helps establish expectations for the client’s conduct in the unit.
A nurse is caring for a client who has a depressive disorder. The client states, "I just can't feel any happiness or joy in life." Which of the following terms should the nurse use when documenting this finding?
- A. Anhedonia
- B. Anergia
- C. Anosognosia
- D. Akathisia
Correct Answer: A
Rationale: The correct answer is A: Anhedonia. Anhedonia refers to the inability to experience pleasure or joy, which is a common symptom of depressive disorders. In this case, the client's statement of not feeling happiness or joy directly aligns with the definition of anhedonia.
Choice B, Anergia, refers to lack of energy or motivation, which is not directly related to the client's statement about not feeling happiness or joy. Choice C, Anosognosia, is a lack of awareness or insight into one's own condition, which is not applicable in this scenario. Choice D, Akathisia, refers to a movement disorder characterized by restlessness, which is not related to the client's emotional state.
In summary, Anhedonia is the most appropriate term to use when documenting the client's inability to feel happiness or joy, as it directly reflects their emotional experience in the context of a depressive disorder.
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.