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An alcoholic client who is completing the inpatient segment of a substance abuse program was placed on disulfiram (Antabuse) drug therapy. What should the nurse include in the discharge instructions?
- A. If disulfiram is taken and alcohol ingested, the client experiences nausea, vomiting and elevated blood pressure.
- B. Disulfiram is most effective when prescribed as late as possible in a recovery program.
- C. Disulfiram works on the desensitization principle.
- D. The effects of disulfiram can be triggered by alcohol 5 days to 2 weeks after the drug is discontinued.
Correct Answer: D
Rationale: When alcohol is ingested with disulfiram therapy, the client experiences nausea, vomiting, and a potentially serious drop in blood pressure. Disulfiram is most successful when used early in the recovery process while the individual makes major lifestyle changes necessary for long-term recovery. Disulfiram works on the classical conditioning principle. The effects of disulfiram can be felt when alcohol is ingested 1-2 weeks after disulfiram is discontinued.
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A client with a history of a stroke is being discharged. The client’s wife asks the nurse how long it will take for her husband to regain his speech. The nurse’s response is based on the knowledge that:
- A. Speech therapy must begin immediately
- B. Most speech recovery occurs within 6 months
- C. Speech recovery cannot be predicted
- D. Speech therapy is not effective after 3 months
Correct Answer: B
Rationale: Most speech recovery post-stroke occurs within the first 6 months, though progress can continue with therapy. Recovery varies, but 6 months is a key period for significant improvement.
The nurse is caring for a client with a history of peripheral artery disease. The nurse should expect the client to have:
- A. Intermittent claudication
- B. Edema in the extremities
- C. Warm extremities
- D. Hyperpigmentation
Correct Answer: A
Rationale: Peripheral artery disease reduces blood flow, causing intermittent claudication (leg pain with activity) due to muscle ischemia.
The nurse begins morning assessment on a male client and notices that she is unable to palpate either of his dorsalis pedis pulses in his feet. What is the first nursing action after assessing this finding?
- A. Palpate these pulses again in 15 minutes.
- B. Use a Doppler to determine presence and strength of these pulses.
- C. Document the finding that the pulses are not palpable.
- D. Call the physician and notify the physician of this finding.
Correct Answer: B
Rationale: Any time during an assessment that the nurse is unable to palpate pulses, the nurse should then obtain a Doppler and assess for presence or absence of the pulse and pulse strength, if a pulse is present.
A measurable outcome criterion in the nursing care of an adolescent with anorexia nervosa would be:
- A. Accepting her present body image
- B. Verbalizing realistic feelings about her body
- C. Having an improved perception of her body image
- D. Exhibiting increased self-esteem
Correct Answer: B
Rationale: This outcome criterion is inadequate because the term 'accepts' is not directly measurable. This outcome criterion is directly measurable because specific goal-related verbalizations can be heard and verified by the nurse. 'Improved perception of body image' is not directly measurable and is therefore open to many interpretations. Although long-term goals for the anorexic client should focus on increased self-esteem, this outcome criterion (as stated) does not include specific indicators or behaviors for which to observe.
A type I diabetic client is diagnosed with cellulitis in his right lower extremity. The nurse would expect which of the following to be present in relation to his blood sugar level?
- A. A normal blood sugar level
- B. A decreased blood sugar level
- C. An increased blood sugar level
- D. Fluctuating levels with a predawn increase
Correct Answer: C
Rationale: Hyperglycemia occurs due to glucose production in response to the stress and illness of cellulitis.