Nokea
A psychiatric unit uses a behavioral approach to determine a client's level of privileges. Which factor should a nurse use to determine an increase in privileges?
- A. Statements that the depression is lifting
- B. An improvement in short-term memory
- C. Performing hygiene activities independently
- D. Verbalizing a desire to change the response to stress
Correct Answer: C
Rationale: Behavioral approaches reward observable actions like hygiene , not just verbal intent (A, D) or memory .
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Imipramine (Tofranil), 75 mg three times per day, is prescribed for a client. What nursing action is appropriate when administering this medication?
- A. Tell the client that barbiturates and steroids will not be prescribed.
- B. Warn the client not to eat cheese, fermenting products, and chicken liver.
- C. Monitor the client for increased tolerance and report if the dosage is no longer effective.
- D. Have the client checked for increased intraocular pressure and teach about symptoms of glaucoma.
Correct Answer: D
Rationale: Imipramine (a tricyclic) can increase intraocular pressure , a key monitoring point.
In the process of development the individual strives to maintain, protect, and enhance the integrity of the self. The nurse determines that this usually is accomplished through the use of:
- A. affective reactions
- B. withdrawal patterns
- C. ritualistic behaviors
- D. defense mechanisms
Correct Answer: D
Rationale: Defense mechanisms protect the ego by managing anxiety and maintaining self-integrity, per psychoanalytic theory.
A client with a paranoid personality disorder makes an inappropriate and unreasonable report to a nurse. What is the most appropriate intervention by the nurse?
- A. Use logic to address the client's concern
- B. Confront the client about the stated misperception
- C. Use nonverbal communication to address the issue
- D. Tell the client too matter-of-factly that you don't share his interpretation
Correct Answer: A
Rationale: Using logic gently challenges the client's perceptions without confrontation, maintaining trust and encouraging reality-testing.
The nursing role that involves being a substitute for another, such as a parent, is called
- A. Counselor
- B. Resource person
- C. Surrogate
- D. Teacher
Correct Answer: C
Rationale: The surrogate role in nursing involves temporarily acting as a substitute figure, like a parent, to meet the client's emotional needs.
A male client voluntarily admits himself to the substance abuse unit. He confesses that he drinks 1 qt or more of vodka each day and uses cocaine occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this condition?
- A. Vomiting, diarrhea, and bradycardia
- B. Dehydration, temperature above 101 F (38.3 C), and pruritus
- C. Hypertension, diaphoresis, and seizures
- D. Diaphoresis, tremors, and nervousness
Correct Answer: D
Rationale: Alcohol withdrawal syndrome includes alcohol withdrawal, alcoholic hallucinosis, and alcohol withdrawal delirium (formerly delirium tremens). Signs of alcohol withdrawal include diaphoresis, tremors, nervousness, nausea, vomiting, malaise, increased blood pressure and pulse rate, sleep disturbances, and irritability. Although diarrhea may be an early sign of alcohol withdrawal, tachycardia—not bradycardia—is associated with alcohol withdrawal. Dehydration and an elevated temperature may be expected, but a temperature above 101 F indicates an infection rather than alcohol withdrawal. Pruritus rarely occurs in alcohol withdrawal. If withdrawal symptoms remain untreated, seizures may arise later.