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During a high school substance abuse class, a student tells the group, “I know that marijuana is not addicting, so why shouldn't I use it? Which response is best for the nurse to provide?
- A. Marijuana is a highly addictive substance.
- B. Altering one's ability to think clearly places self and others at risk.
- C. Healthcare providers sometimes prescribe marijuana to control nausea.
- D. Drug use has moral implications that should be discussed with parents.
Correct Answer: B
Rationale: This response highlights the immediate risk of impaired thinking, emphasizing potential harm to self and others from marijuana use.
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A male client arrives at the mental health clinic and asks the nurse for more lithium and the antidepressant amitriptyline that he uses to help him sleep. After reviewing the assessment findings with the healthcare provider, a serum creatinine is obtained. Which information supports the reason for this laboratory test?
- A. Creatinine can measure how the body is metabolizing the lithium in the liver.
- B. The effects of amitriptyline can promote and potentiate the risk of lithium toxicity.
- C. The combination of lithium and amitriptyline may need to be changed if creatinine is high.
- D. Lithium is excreted by the kidneys, and creatinine is related to kidney functioning.
Correct Answer: D
Rationale: Lithium is excreted by the kidneys, and monitoring creatinine levels assesses renal function, guiding dosage to prevent toxicity.
A young adult male client is admitted to the psychiatric unit because of a recent suicide attempt. His wife filed for divorce six months ago, he lost his job three months ago, and his best friend moved to another city two weeks ago. Which intervention should the nurse include in this client's plan of care?
- A. Avoid discussing subjects that upset the client.
- B. Encourage activities that allow the client to exert control over his environment.
- C. Allow the client time alone to sort out his feelings.
- D. Encourage the client to interact with persons who are recovering from depression.
Correct Answer: B
Rationale: Encouraging activities that allow the client to exert control over his environment helps empower the client and regain a sense of agency, which is critical for improving mental health post-suicide attempt.
The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?
- A. A young woman who suddenly goes blind with no indication of organic pathology.
- B. An older adult who continuously complains of a headache and back pain.
- C. An adolescent who becomes extremely anxious about going outside.
- D. A middle-aged man who is complaining of shortness of breath and is diaphoretic.
Correct Answer: A
Rationale: Sudden blindness with no organic pathology is indicative of a conversion disorder, involving neurological symptoms without a neurological basis.
The nurse completes an assessment of a client experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?
- A. A summary of the client's feelings.
- B. The client's significant other's statement.
- C. A general description.
- D. Photographs.
Correct Answer: D
Rationale: Photographs provide objective and visual documentation of the injuries, offering a clear and accurate record for legal and healthcare purposes.
An adolescent who is a heroin addict is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?
- A. Assess intake and output.
- B. Monitor for wheezing and apnea.
- C. Limit visitors to family members only.
- D. Assign the client to a teen support group.
Correct Answer: B
Rationale: Monitoring for wheezing and apnea is crucial during the first 24 hours of heroin detoxification to ensure respiratory stability, addressing immediate physiological risks.