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A nurse is discussing the manifestations of alcohol withdrawal with a client who has a history of alcohol use disorder. Which of the following client statements indicates understanding?
- A. "I should expect tremors to start less than 24 hours after I stop drinking."
- B. "Disulfiram will block my cravings for alcohol."
- C. "My symptoms should last about 5 to 7 days once they begin."
- D. "It is important that I take vitamin C to prevent cirrhosis or other liver damage."
Correct Answer: A
Rationale: The correct answer is A because alcohol withdrawal symptoms, including tremors, typically begin within 6-24 hours after the last drink. This statement shows an accurate understanding of the timing of alcohol withdrawal manifestations. Choice B is incorrect because Disulfiram is a medication used to deter alcohol consumption, not block cravings. Choice C is incorrect because alcohol withdrawal symptoms can last beyond 5-7 days. Choice D is incorrect because vitamin C does not prevent cirrhosis or liver damage from alcohol abuse.
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Which action is most therapeutic for a client with panic-level anxiety?
- A. Suggest the client rest in bed
- B. Remain with the client
- C. Medicate the client with a sedative
- D. Have the client join a therapy group
Correct Answer: B
Rationale: The correct answer is B: Remain with the client. This is the most therapeutic action because it provides immediate reassurance and support to the client, helping to reduce feelings of isolation and fear during a panic attack. By staying with the client, you can offer comfort and help them feel safe and supported.
Choice A is incorrect as suggesting the client rest in bed may not address their immediate needs during a panic attack. Choice C, medicating the client with a sedative, may provide short-term relief but does not address the underlying causes of the anxiety. Choice D, having the client join a therapy group, is not suitable during a panic attack as the client needs immediate support and intervention.
A nurse is admitting a client who is about to undergo surgery for benign prostatic hypertrophy. The client states, 'I don't know what I will do if they find I have cancer.' Which of the following responses should the nurse make?
- A. Why do you think you might have cancer when your diagnosis is a benign condition?'
- B. I'm looking at your chart here and I don't see any reason for you to worry about that.'
- C. I think that's something you need to discuss with your provider.'
- D. I'm hearing that you are concerned that it might turn out that you have cancer.'
Correct Answer: D
Rationale: Rationale: The correct response is D because it acknowledges the client's fear and validates their emotions. By reflecting back the client's statement, the nurse shows empathy and understanding. This approach helps build trust and rapport with the client, fostering open communication. Choice A is dismissive and does not address the client's feelings. Choice B is invalidating and can increase the client's anxiety. Choice C deflects the client's emotions instead of addressing them directly. In summary, option D is the best response as it demonstrates active listening and empathy, promoting a therapeutic nurse-client relationship.
A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions is the highest priority?
- A. Protecting the client from injury.
- B. Determining the cause of the client’s anxiety.
- C. Ensuring that the client feels safe.
- D. Identifying the client’s coping skills.
Correct Answer: A
Rationale: The correct answer is A: Protecting the client from injury. This is the highest priority because ensuring the client's physical safety takes precedence in a crisis situation. If the client is at risk of harming themselves or others, immediate action must be taken to prevent injury. Determining the cause of anxiety, ensuring the client feels safe, and identifying coping skills are important but secondary priorities once the client's safety is assured. In a crisis situation, physical safety is paramount before addressing underlying causes or providing emotional support.
A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which of the following interventions should the nurse identify as the priority?
- A. Helping the client identify positive personality traits
- B. Providing for adequate hydration and rest
- C. Confronting the use of denial and other defense mechanisms
- D. Educating the client about the consequences of alcohol misuse
Correct Answer: B
Rationale: The correct answer is B: Providing for adequate hydration and rest. The priority in caring for a client with alcohol use disorder is addressing physical needs like hydration and rest to manage withdrawal symptoms and prevent complications. Hydration helps prevent dehydration and electrolyte imbalances, while rest supports the body's healing process. Choices A, C, and D focus on psychological aspects, which are important but secondary to addressing immediate physical needs. Helping the client identify positive traits can come later in therapy, confronting denial and defense mechanisms can be addressed once the client is stabilized, and educating about consequences is important but not as urgent as ensuring hydration and rest.
A nurse is caring for a client who has bipolar disorder and is running around the unit asking people to dance with her. Which of the following interventions should the nurse take?
- A. Turn on a dance video so the client can burn off excess energy.
- B. Offer the client a low-calorie snack in return for stopping the behavior.
- C. Walk the client outside and sit with her in the garden area.
- D. Observe the client closely for the development of aggressive behavior.
Correct Answer: C
Rationale: The correct answer is C: Walk the client outside and sit with her in the garden area. This intervention helps the client to redirect their energy in a positive and calming manner. Being outdoors can provide a change of environment, fresh air, and can help the client feel more grounded. It also offers a distraction from the impulsive behavior and promotes relaxation. Turning on a dance video (choice A) may further stimulate the client's behavior rather than calming them down. Offering a snack (choice B) may reinforce the behavior and is not addressing the underlying issue. Observing for aggressive behavior (choice D) is important but does not actively address the client's current behavior.