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Following involvement in a motor vehicle collision, a middle-aged adult client is admitted to the hospital with multiple facial fractures. The client's blood alcohol level is high on admission. Which PRN prescription should be administered if the client begins to exhibit signs and symptoms of delirium tremens (DTs)?
- A. Prochlorperazine 5 mg IM
- B. Hydromorphone 2 mg IM
- C. Lorazepam 2 mg IM
- D. Chlorpromazine 50 mg IM
Correct Answer: C
Rationale: Lorazepam is a benzodiazepine used to manage delirium tremens (DTs), a severe form of alcohol withdrawal, by reducing agitation and preventing seizures. Prochlorperazine and chlorpromazine are antipsychotics, not first-line for DTs. Hydromorphone is an opioid and inappropriate for DTs management.
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The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessment?
- A. The snakes on the wall are going to eat me
- B. The nurse at night is trying to poison me with pills
- C. The voices are telling me to kill the next person I see
- D. The fire is burning my skin away right now
- E. None
- F. None
Correct Answer: B
Rationale: The nurse at night is trying to poison me with pills' confirms a delusion, specifically a paranoid delusion, as it reflects a fixed, false belief not based in reality. The other options describe hallucinations: visual ('snakes'), auditory ('voices'), and tactile ('fire'). Delusions involve false beliefs, while hallucinations involve false sensory perceptions.
Mark whether the statement by the student nurse indicates understanding or no understanding.
- A. If the client decides not to report their friend to the police, it is still a good idea to collect the evidence': Understanding
- B. Even if the client will not call the police, the nurse should advise the police of what has happened': No understanding
- C. The client has to consent in order for me to document his injuries in the chart': Understanding
- D. Consent is not required to collect evidence from a person who has been sexually assaulted': No understanding
- E. The sexual assault exam should only be done by a Sexual Assault Nurse Examiner, the Emergency Room attending physician, or other expert': Understanding
Correct Answer: A,B,C,D,E
Rationale: A: Collecting evidence preserves options (Understanding). B: Reporting without consent violates autonomy (No understanding). C: Consent is required for documentation (Understanding). D: Consent is always required for evidence collection (No understanding). E: Exams require trained professionals (Understanding).
The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?
- A. Participates in individual and group therapy
- B. Demonstrates effective ways to cope with anxiety
- C. Learns methods of relaxation to reduce anxiety
- D. Takes all antianxiety medications as prescribed
Correct Answer: B
Rationale: This outcome directly addresses the client's maladaptive coping mechanism (scratching wrists) by aiming to replace it with healthier strategies. Therapy participation and relaxation methods are important but secondary to effective coping. Medication adherence does not teach alternative coping strategies.
A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?
- A. Ask the client to describe and identify the source of the feelings
- B. Provide education about ways to cope with anxiety
- C. Assist the client with relaxation techniques in the group
- D. Escort the client from the group to reduce stimuli
Correct Answer: C
Rationale: Assisting the client with relaxation techniques in the group is the best intervention as it provides immediate support and can help alleviate the client's anxiety in the moment. Exploring the source of anxiety may not be suitable during a group session where immediate relief is needed. Education on coping mechanisms is valuable but does not address immediate needs. Escorting the client out may be considered if anxiety becomes overwhelming, but it is secondary to attempting in-group relaxation.
In conducting the initial assessment of a preoperative client, the nurse notes that the client's home medications include the monoamine oxidase (MAO) inhibitor phenelzine. Because of this client's medication history, which assessment finding is most important for the nurse to monitor?
- A. Blood pressure
- B. Urinary output
- C. Respiratory rate
- D. Temperature
Correct Answer: A
Rationale: MAO inhibitors like phenelzine can cause hypertensive crises, especially with certain foods or medications. Monitoring blood pressure is critical to detect this life-threatening complication. Urinary output, respiratory rate, and temperature are less directly affected by MAO inhibitors.