Nokea
If the angry client is out of control and refuses a p.r.n. sedative medication, the nurse has which legal option?
- A. The nurse must respect the client's right to refuse the ordered medication.
- B. The nurse must administer the medication to protect the safety of self and others.
- C. The nurse must get permission from a probate court judge to administer the medication.
- D. The nurse should ask the hospital's attorney about the client's right to refuse treatment.
Correct Answer: A
Rationale: Clients have the right to refuse medication unless they pose an imminent danger, in which case emergency protocols may apply, but respect for autonomy is primary.
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When the nurse reviews information about lithium carbonate (Lithane) with the client, which instructions are most important to stress? Select all that apply.
- A. Take a high-potency vitamin each morning.
- B. Refrain from sexual activity while taking this medication.
- C. Notify the physician if urine output increases.
- D. Maintain an adequate intake of sodium and fluids.
- E. Have periodic blood tests to monitor serum levels of the drug.
Correct Answer: C,D,E
Rationale: Monitoring urine output, maintaining sodium/fluid balance, and regular blood tests are critical to prevent lithium toxicity and ensure safe therapy.
Which of the following nursing assessment data places the client at highest risk for suicide?
- A. The client feels hopeless about the future.
- B. The client has a plan in mind for suicide.
- C. The client states that death would end the misery.
- D. The client says the distress is intolerable.
Correct Answer: B
Rationale: A specific suicide plan indicates high risk, as it shows intent and means, requiring immediate intervention.
Which of the following identified assessment criteria is the highest priority for this client?
- A. The number of characteristics of the client's bowel movements
- B. How much the client knows about colostomy care
- C. Which coping mechanisms the client uses for handling stress
- D. The types of relationships the client has with peers
Correct Answer: A
Rationale: Monitoring bowel movements is critical in ulcerative colitis to assess disease activity and guide treatment, prioritizing physical health.
The hospitalized client has a history of weekly moderate alcohol use. Which symptoms assessed by the nurse indicate that the client may be experiencing alcohol withdrawal? Select all that apply.
- A. Agitation
- B. Hypotension
- C. Tachycardia
- D. Hallucinations
- E. Tongue tremor
Correct Answer: A, C ,D ,E
Rationale: Withdrawal causes agitation (A) tachycardia (C) hallucinations (D) and tongue tremor (E) via NMDA receptor activity. Hypotension (B) is incorrect; hypertension occurs.
The nurse is assessing the college student who presents with generalized fatigue dry mouth tachycardia and an increased appetite. Which additional finding from the client’s history and physical exam should alert the nurse to explore possible marijuana abuse?
- A. Paranoia
- B. Flashbacks
- C. Gastric disturbances
- D. Conjunctival infection
Correct Answer: D
Rationale: Conjunctival infection (D) is a marijuana sign with fatigue dry mouth tachycardia and appetite increase. Paranoia (A) is methamphetamine flashbacks (B) are hallucinogens gastric issues (C) are alcohol.