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In the situation presented, which nursing intervention constitutes false imprisonment?
- A. The client is combative and will not redirect, stating, No one can stop me from leaving. The nurse seeks the physicians order after the client is restrained.
- B. The client has been consistently seeking the attention of the nurses much of the day. The nurse institutes seclusion.
- C. A psychotic client, admitted in an involuntary status, runs off the psychiatric unit. The nurse runs after the client and the client agrees to return.
- D. A client hospitalized as an involuntary admission attempts to leave the unit. The nurse calls the security team and they prevent the client from leaving.
Correct Answer: A
Rationale: The correct answer is A because false imprisonment occurs when a person is unlawfully restrained. In this scenario, the client is restrained without a physician's order, which is considered unlawful. Seeking a physician's order after the client is already restrained does not justify the action.
Choice B is incorrect because seclusion is a valid nursing intervention for managing disruptive behavior, as long as it is done in a safe and ethical manner.
Choice C is incorrect because the nurse's actions of running after the client and convincing them to return do not constitute false imprisonment.
Choice D is incorrect because preventing a client hospitalized as an involuntary admission from leaving with the help of security is a valid intervention to ensure the safety of the client and others.
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A client is taking chlordiazepoxide (Librium) for generalized anxiety disorder symptoms. In which situation should a nurse recognize that this client is at greatest risk for drug overdose?
- A. When the client has a knowledge deficit related to the effects of the drug
- B. When the client combines the drug with alcohol
- C. When the client takes the drug on an empty stomach
- D. When the client fails to follow dietary restrictions
Correct Answer: B
Rationale: The correct answer is B: When the client combines the drug with alcohol. Combining chlordiazepoxide with alcohol can potentiate the central nervous system depression effects, leading to respiratory depression, sedation, and potential overdose. Alcohol can enhance the sedative effects of chlordiazepoxide, increasing the risk of overdose. A, C, and D are incorrect because a knowledge deficit, taking the drug on an empty stomach, or failing to follow dietary restrictions are not directly related to increasing the risk of drug overdose in this specific scenario.
From an interpersonal theory perspective, which intervention would a nurse use to assist a client diagnosed with major depressive disorder?
- A. Offer family therapy sessions
- B. Discuss childhood events
- C. Teach alternate coping skills
- D. Encourage discussion of feelings
Correct Answer: A
Rationale: The correct answer is A because family therapy sessions can help address underlying family dynamics contributing to the client's depression. This intervention aligns with interpersonal theory, which focuses on improving relationships and communication within the client's social network. Family therapy can enhance support systems and promote healthier interactions.
Option B is incorrect as discussing childhood events may not directly address current interpersonal difficulties. Option C, teaching coping skills, is helpful but may not target the interpersonal issues specific to major depressive disorder. Option D, encouraging discussion of feelings, is important but may not address the broader interpersonal dynamics impacting the client's condition.
What is the purpose of a nurse providing appropriate feedback?
- A. To give the client good advice
- B. To advise the client on appropriate behaviors
- C. To evaluate the clients behavior
- D. To give the client critical information
Correct Answer: C
Rationale: The purpose of a nurse providing appropriate feedback is to evaluate the client's behavior. This involves assessing the client's actions, understanding their needs, and determining the effectiveness of the care provided. Feedback helps in identifying areas for improvement and guiding the client towards better health outcomes. Choice A is incorrect as feedback is not solely about giving advice. Choice B is incorrect as feedback is not limited to advising on behaviors. Choice D is incorrect as feedback goes beyond just providing critical information to include a holistic evaluation of the client's overall behavior and progress.
A nursing instructor is teaching about the monoamine category of neurotransmitters. Which student statement indicates that learning about the function of norepinephrine has occurred?
- A. Norepinephrine functions to regulate mood, cognition, and perception.
- B. Norepinephrine functions to regulate arousal, libido, and appetite.D. Norepinephrine functions to regulate pain, inflammatory response, and wakefulness.
Correct Answer: B
Rationale: The correct answer is B because norepinephrine is primarily involved in regulating arousal, libido, and appetite. This neurotransmitter is released in response to stress or danger, increasing alertness and readiness for action. Choices A and C are incorrect because they describe the functions of serotonin and dopamine, respectively. Serotonin regulates mood, cognition, and perception, while dopamine is involved in pain modulation, inflammatory response, and wakefulness. Therefore, choice B is the most appropriate in indicating learning about the function of norepinephrine.
A nurse is interviewing a distressed client, who relates being fired after 15 years of loyal employment. Which of the following questions would best assist the nurse to determine the clients appraisal of the situation? Select all that apply.
- A. What resources have you used previously in stressful situations?
- B. Have you ever experienced a similar stressful situation?
- C. Who do you think is to blame for this situation?
- D. Why do you think you were fired from your job?
Correct Answer: A
Rationale: The correct answer is A: "What resources have you used previously in stressful situations?" This question is the best choice as it focuses on understanding the client's coping mechanisms and resilience. By asking about previous resources used, the nurse can assess the client's strengths and support systems.
Choice B is incorrect because asking if the client has experienced a similar situation does not directly address the client's current appraisal of the situation.
Choice C is incorrect as it focuses on assigning blame, which may not be helpful in understanding the client's perspective and emotions.
Choice D is also incorrect because asking why the client thinks they were fired may lead to a defensive response and may not necessarily provide insight into the client's appraisal of the situation.