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A nurse is discussing short- and long-term goals with a client who has alcohol use disorder and is being admitted to a treatment facility. Which of the following statements is appropriate for the nurse to include in the discussion?
- A. You will be taking a once-weekly dose of disulfiram to help control withdrawal symptoms during treatment
- B. Remaining physically active will help to minimize drowsiness and chills associated with initial alcohol withdrawal
- C. Attending Al-Anon meetings will help you identify a role model to assist you with making needed changes
- D. You will begin learning functional skills to replace defense mechanisms and behaviors while in treatment
Correct Answer: D
Rationale: Correct Answer: D: You will begin learning functional skills to replace defense mechanisms and behaviors while in treatment
Rationale: This statement is appropriate because it focuses on the core aspect of treatment for alcohol use disorder, which is addressing maladaptive coping mechanisms with healthier alternatives. By learning functional skills to replace defense mechanisms and behaviors, the client can develop healthier coping strategies and decrease the likelihood of relapse in the long term.
Summary of other choices:
A: Incorrect - Disulfiram is not used to control withdrawal symptoms; it is a deterrent medication to discourage alcohol consumption.
B: Incorrect - Physical activity is beneficial, but it does not directly address the underlying issues of alcohol use disorder.
C: Incorrect - Al-Anon meetings are for family and friends of individuals with substance use disorders, not for the individual seeking treatment.
E, F, G: No information provided.
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A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following actions should the nurse take first?
- A. Refer the family to a grief support group.
- B. Determine the roles of individual family members.
- C. Encourage the family to assign specific tasks to individual family members.
- D. Assist the family to establish a daily routine.
Correct Answer: B
Rationale: The correct answer is B: Determine the roles of individual family members. This is the first step because understanding the roles within the family will help identify strengths and resources to support them through the grieving process. By determining roles, the nurse can assess each family member's needs and abilities, facilitating targeted interventions. Referral to a grief support group (A) may be beneficial later, but understanding family dynamics comes first. While assigning tasks (C) and establishing a routine (D) are important, they should come after identifying roles to ensure they are tailored to the family's specific needs.
A nurse is teaching a group of school-age children about healthy snack options. Which of the following snacks should the nurse include?
- A. Cheesecake
- B. Air-popped popcorn
- C. Milkshake made with whole milk
- D. Baked potato chips
Correct Answer: B
Rationale: The correct answer is B: Air-popped popcorn. Popcorn is a whole grain snack that is high in fiber and low in calories, making it a healthy option for school-age children. It provides sustained energy and promotes satiety. It is also a good source of vitamins and minerals. Cheesecake (A) is high in sugar and saturated fat, not a healthy choice. Milkshake made with whole milk (C) is high in sugar and saturated fat, lacking nutritional value. Baked potato chips (D) are still high in fat and calories compared to air-popped popcorn. Overall, air-popped popcorn is the best choice among the options provided for a healthy snack for school-age children.
A hospice nurse is talking with the partner of a client who is near death. The partner states, 'How will I go on without them? I already feel alone.' Which of the following actions should the nurse take?
- A. Express sympathy to the client's partner.
- B. Ask the client's partner if they need anything.
- C. Hug the client's partner.
- D. Reassure the client's partner that it will get better.
Correct Answer: A
Rationale: Correct Answer: A: Express sympathy to the client's partner.
Rationale: Expressing sympathy acknowledges the partner's emotions, validates their feelings, and shows empathy. It helps the partner feel heard and supported during a difficult time. This action focuses on the partner's emotional needs, offering comfort and understanding.
Summary:
B: Asking if the partner needs anything is helpful but may not address the emotional distress directly.
C: Hugging without consent may not be appropriate and could make the partner uncomfortable.
D: Reassuring without acknowledging the partner's feelings may come across as dismissive and invalidating.
A home health nurse is caring for a client who has chemotherapy-induced nausea that has been resistant to relief from pharmacological measures. Which of the following interventions should the nurse initiate? (Select all that apply)
- A. Use seasonings to enhance the flavor of foods
- B. Provide sips of room temperature ginger ale between meals
- C. Maintain the head of the client's bed in an elevated position after eating
- D. Offer 120 ml (4 oz.) of cold 2% milk as a meal replacement
- E. Assist the client in using guided imagery
Correct Answer: B, C, E
Rationale: The correct interventions for the client with chemotherapy-induced nausea are B, C, and E.
B: Providing sips of room temperature ginger ale can help alleviate nausea due to its antiemetic properties.
C: Maintaining the head of the client's bed in an elevated position after eating can prevent acid reflux and reduce nausea.
E: Assisting the client in using guided imagery can help distract from nausea and promote relaxation.
Incorrect choices:
A: Using seasonings may exacerbate nausea in some clients.
D: Offering cold milk as a meal replacement may not be well-tolerated by a nauseated client and could worsen symptoms.
In summary, the correct interventions focus on soothing the stomach, promoting relaxation, and preventing exacerbation of nausea, while the incorrect choices may not directly address the client's symptoms or could potentially worsen them.
A nurse is counseling a client who is to undergo enzyme-linked immunosorbent assay (ELISA) testing for HIV. Which of the following information should the nurse include?
- A. The test monitors progression of the disease
- B. The test measures antibodies to the virus
- C. The test results are accurate 24 hr after exposure to the virus
- D. A positive result requires initiating immunoglobulin administration
Correct Answer: B
Rationale: The correct answer is B because ELISA testing for HIV measures antibodies to the virus, indicating exposure to the virus. This is crucial for diagnosing HIV infection. Choice A is incorrect because ELISA does not monitor disease progression. Choice C is incorrect as it takes weeks, not hours, for accurate results post-exposure. Choice D is incorrect as immunoglobulin administration is not the treatment for a positive HIV result.