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A client is experiencing alcohol withdrawal. Which symptom should the nurse identify as a priority to address?
- A. Tremors
- B. Nausea and vomiting
- C. Increased blood pressure
- D. Insomnia
Correct Answer: C
Rationale: During alcohol withdrawal, increased blood pressure is a critical symptom that requires immediate attention. Elevated blood pressure can lead to serious complications such as cardiovascular events or stroke. Monitoring and managing blood pressure in clients experiencing alcohol withdrawal is crucial to prevent adverse outcomes. Tremors, nausea and vomiting, and insomnia are common symptoms of alcohol withdrawal, but they are not as immediately life-threatening as increased blood pressure. Therefore, addressing increased blood pressure takes precedence in the management of a client experiencing alcohol withdrawal.
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A client with depression is experiencing anhedonia. Which statement by the client reflects this symptom?
- A. I feel so anxious all the time.
- B. I don't enjoy the things I used to love.
- C. I can't concentrate on anything.
- D. I have trouble sleeping through the night.
Correct Answer: B
Rationale: Anhedonia is the inability to experience pleasure from activities usually found enjoyable. The statement 'I don't enjoy the things I used to love' directly reflects this symptom as the client is expressing a lack of pleasure from previously enjoyable activities. Choices A, C, and D do not specifically relate to anhedonia but rather indicate symptoms of anxiety, concentration difficulties, and sleep disturbances, respectively.
A client with obsessive-compulsive disorder (OCD) is being cared for by a nurse. Which intervention should the nurse implement to help the client manage compulsive behaviors?
- A. Encourage the client to suppress compulsive behaviors.
- B. Allow the client to perform compulsive behaviors with limits.
- C. Teach the client relaxation techniques to manage anxiety.
- D. Discourage the client from performing compulsive behaviors.
Correct Answer: B
Rationale: Allowing the client to perform compulsive behaviors with limits is a therapeutic intervention for managing OCD. This approach grants the client some autonomy while ensuring that the behaviors do not excessively disrupt daily life. Setting boundaries helps structure the behaviors, decreasing anxiety and distress associated with OCD. Encouraging the client to suppress compulsive behaviors (choice A) may lead to increased anxiety and potential worsening of symptoms. Teaching relaxation techniques (choice C) is beneficial for managing anxiety in general but may not directly address the compulsive behaviors. Discouraging the client from performing compulsive behaviors (choice D) without providing alternative strategies or support may increase distress and resistance.
A client with bipolar disorder is experiencing a depressive episode. Which nursing intervention is most appropriate?
- A. Encourage the client to avoid physical activity.
- B. Encourage the client to engage in social activities.
- C. Encourage the client to participate in group therapy.
- D. Encourage the client to set realistic goals.
Correct Answer: C
Rationale: Encouraging the client to participate in group therapy is the most appropriate nursing intervention for a client with bipolar disorder experiencing a depressive episode. Group therapy provides a supportive environment where the client can share experiences, learn coping strategies, and receive emotional support from peers and mental health professionals. It can help reduce feelings of isolation, improve social skills, and enhance overall well-being. Group therapy also promotes a sense of belonging and understanding, which are essential for individuals dealing with bipolar disorder and depressive symptoms. Choices A, B, and D are not the most appropriate interventions for a client experiencing a depressive episode in bipolar disorder. Encouraging the client to avoid physical activity may worsen their symptoms, promoting social activities may not address the underlying issues effectively, and setting goals may be overwhelming during a depressive episode.
A healthcare provider is assessing a client who has been diagnosed with conversion disorder. Which of the following findings should the provider expect?
- A. Paralysis of a limb
- B. Auditory hallucinations
- C. Dissociative amnesia
- D. Compulsive behaviors
Correct Answer: A
Rationale: Conversion disorder is characterized by the development of neurological symptoms, such as paralysis of a limb, that cannot be explained by medical evaluation. The paralysis is typically due to a psychological conflict or stress rather than a physical issue. Auditory hallucinations, dissociative amnesia, and compulsive behaviors are not commonly associated with conversion disorder, making them incorrect choices. Therefore, the healthcare provider should expect to find paralysis of a limb in a client with conversion disorder.
A client is experiencing a moderate level of anxiety. Which is an example of an appropriate nursing intervention?
- A. Allow the client to pace in a safe environment.
- B. Encourage the client to discuss feelings.
- C. Help the client identify the cause of anxiety.
- D. Provide a distraction for the client.
Correct Answer: A
Rationale: Allowing the client to pace in a safe environment is an appropriate nursing intervention for managing moderate anxiety levels. Allowing pacing provides the client with a physical outlet for their anxiety and can help them release nervous energy without increasing distress. It promotes movement and can aid in reducing feelings of restlessness or agitation. Encouraging the client to discuss feelings (Choice B) is more suitable for addressing emotional aspects of anxiety rather than providing an immediate physical outlet. Helping the client identify the cause of anxiety (Choice C) may be more appropriate for long-term management but may not address the immediate need for physical release. Providing a distraction (Choice D) may not directly address the physical needs associated with moderate anxiety levels.