Nokea
In this situation, which nursing action is most appropriate?
- A. Placing restraints on the client's arms and legs
- B. Reassuring the client that the bugs are imaginary
- C. Reporting the behavior to the doctor to obtain a sedative order
- D. Closing the client's door so that others are not alarmed
Correct Answer: C
Rationale: Reporting delirium tremens symptoms, like hallucinations, to the physician ensures timely medical intervention for alcohol withdrawal.
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Which nursing action is especially important when administering medications to a depressed client?
- A. Encouraging the client to drink a full glass of water
- B. Checking that the client has swallowed all oral medications
- C. Giving the medications on an empty stomach before meals
- D. Having the client take each medication separately
Correct Answer: B
Rationale: Ensuring medications are swallowed prevents hoarding, a risk in depressed clients with suicidal ideation.
The nurse is teaching home health aides about monitoring for alcohol abuse in older adults. Which response by a home health aide indicates a need for further teaching?
- A. “Alcohol abuse is the largest category of substance abuse problems in older adults.”
- B. “I should monitor more closely for alcohol abuse in single male clients who smoke.”
- C. “Retirement and freedom from work and family pressures tend to decrease alcohol use.”
- D. “Confusion malnutrition and self-neglect may be signs of alcohol abuse in the elderly.”
Correct Answer: C
Rationale: Retirement can increase alcohol use due to isolation (C is incorrect). Alcohol is a major issue (A) risk factors include male smokers (B) and signs include confusion (D).
During a home visit, which assessment finding is most suggestive that the client is experiencing auditory hallucinations?
- A. The client sings a song while walking around the room.
- B. The client quickly changes the topic of conversation.
- C. The client repeats a sentence over and over again.
- D. The client turns an ear as if listening to someone.
Correct Answer: D
Rationale: Turning an ear as if listening suggests the client is responding to auditory hallucinations, a common symptom in schizophrenia.
The nurse is caring for the client who has methamphetamine toxicity. Which interventions should the nurse include in the client’s plan of care? Select all that apply.
- A. Give olanzapine 10 mg IM q2h prn to treat agitation.
- B. Allow the client to sleep and eat as much as desired.
- C. Administer labetalol 20 mg IV to control hallucinations.
- D. Monitor 1:1 to protect client from harm to self and others.
- E. Encourage involvement in the therapeutic treatment milieu.
Correct Answer: A ,B ,D
Rationale: Olanzapine (A) reduces agitation sleep/eating (B) aids recovery 1:1 monitoring (D) ensures safety. Labetalol (C) is for BP not hallucinations; milieu (E) is premature.
The client in group therapy states “I’ve enjoyed using methylphenidate because of how it makes me feel.” The nurse should identify which additional statement with methylphenidate use?
- A. “I love how it gave me energy to stay up all night.”
- B. “It really helped me sleep when I wasn’t very tired.”
- C. “The bad part was that I gained weight when using it.”
- D. “I could really focus. I liked not worrying about anything.”
Correct Answer: D
Rationale: Methylphenidate aids focus (D). Energy (A) is amphetamine it doesn’t aid sleep (B) and causes weight loss (C).