Nokea
If the client's drug screen is positive for cocaine, it is most appropriate for the nurse to advise a staff person to monitor the client closely for which finding?
- A. Cardiac arrhythmias
- B. Depressed respirations
- C. Low heart rate
- D. Elevated blood glucose level
Correct Answer: A
Rationale: Cocaine's stimulant effects increase the risk of cardiac arrhythmias, a potentially life-threatening complication requiring close monitoring.
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When a 24-year-old with a record of multiple convictions for driving under the influence (DUI) claims not to be an alcoholic, which is the most pertinent assessment question the nurse can ask?
- A. When you drink, do you drink beer or hard liquor?
- B. Did you begin drinking before or after you were of legal age?
- C. Do you prefer to drink alcohol rather than soft drinks?
- D. Are you unable to recall events that occurred while drinking?
Correct Answer: D
Rationale: Asking about memory loss during drinking episodes assesses for blackouts, a key indicator of problematic drinking patterns associated with alcoholism.
Which information is most appropriate for the nurse to tell the client about taking alprazolam (Xanax)?
- A. Avoid consuming alcohol while taking this drug.
- B. Take the medication with a full meal.
- C. This drug can cause insomnia in some people.
- D. A blood test will be required periodically.
Correct Answer: A
Rationale: Alcohol potentiates alprazolam's sedative effects, increasing the risk of respiratory depression and overdose, making this a critical instruction.
Which technique is best for reducing confusion among clients with dementia?
- A. Wear an employee name tag when caring for clients.
- B. Adhere to a consistent routine of unit activities.
- C. Provide diversional activities such as field trips.
- D. Distribute a list of the day's scheduled events.
Correct Answer: B
Rationale: A consistent routine minimizes confusion by providing predictability, supporting cognitive stability in dementia.
The client is placed in seclusion for exhibiting violent behavior. Which should be the nurse’s primary goal of this seclusion?
- A. Assist the client in regaining self-control
- B. Assure the safety of the client and others
- C. Regain control over the unit’s environment
- D. Provide a consequence for the client’s behavior
Correct Answer: B
Rationale: Safety of client and others (B) is the primary seclusion goal by reducing stimuli. Self-control (A) and unit control (C) are outcomes and punishment (D) is inappropriate.
Which form of instruction is most beneficial when preparing the anxious client?
- A. Provide detailed explanations.
- B. Use short, simple sentences.
- C. Draw elaborate diagrams.
- D. Show a teaching DVD.
Correct Answer: B
Rationale: Short, simple sentences are easier for an anxious client to process, reducing cognitive overload and improving comprehension.