Nokea
A patient in an alcohol treatment program says, 'I have been a loser all my life. I'm so ashamed of what I have put my family through. Now, I'm not even sure I can succeed at staying sober.' Which nursing diagnosis applies?
- A. Chronic low self-esteem
- B. Situational low self-esteem
- C. Disturbed personal identity
- D. Ineffective health maintenance
Correct Answer: A
Rationale: Lifelong feelings of inadequacy indicate chronic low self-esteem.
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Which nursing diagnosis would likely apply both to a patient diagnosed with schizophrenia as well as a patient diagnosed with amphetamine-induced psychosis?
- A. Powerlessness
- B. Disturbed thought processes
- C. Ineffective thermoregulation
- D. Impaired oral mucous membrane
Correct Answer: B
Rationale: Both conditions involve paranoid delusions, making disturbed thought processes appropriate.
When assessing a patient who has ingested flunitrazepam, what should the nurse expect?
- A. Acrophobia
- B. Hypothermia
- C. Hallucinations
- D. Anterograde amnesia
Correct Answer: D
Rationale: Flunitrazepam causes anterograde amnesia, disinhibition, and muscle relaxation.
In what significant ways is the therapeutic environment different for a patient who has ingested lysergic acid diethylamide (LSD) than for a patient who has ingested phencyclidine (PCP)?
- A. For LSD ingestion, one person stays with the patient and provides verbal support. For PCP ingestion, a regimen of limited contact with staff members is maintained, and continual visual monitoring is provided.
- B. For PCP ingestion, the patient is placed on one-on-one intensive supervision. For LSD ingestion, a regimen of limited interaction and minimal verbal stimulation is maintained.
- C. For LSD ingestion, continual moderate sensory stimulation is provided. For PCP ingestion, continual high-level stimulation is provided.
- D. For LSD ingestion, the patient is placed in restraints. For PCP ingestion, seizure precautions are implemented.
Correct Answer: A
Rationale: LSD patients benefit from verbal support, while PCP patients require minimal stimulation due to violent tendencies.
Select the most appropriate outcome for a patient completing the fourth alcohol detoxification program in 1 year. Before discharge, what will the patient do?
- A. Use rationalization in healthy ways.
- B. State, 'I see the need for ongoing treatment.'
- C. Identify constructive outlets for expression of anger.
- D. Develop a trusting relationship with one staff member.
Correct Answer: B
Rationale: Recognizing the need for ongoing treatment is key to preventing relapse.
A patient is admitted in a comatose state after ingesting five capsules of lorazepam. A friend of the patient says, 'Often my friend drinks, along with taking more of the drug than is prescribed.' What is the effect of the use of alcohol with this drug?
- A. The drug's metabolism is stimulated.
- B. The drug's effect is diminished.
- C. A synergistic effect occurs.
- D. There is no effect.
Correct Answer: C
Rationale: Alcohol and lorazepam, both CNS depressants, have synergistic effects, potentiating each other.