Nokea
The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore in-depth with the client based on this screening tool?
- A. Cancer screening result and gastritis daily alcohol intake.
- B. Consumption, liver enzyme gastrointestinal complaints, and bleeding.
- C. Efforts to cut down, annoyance with questions, guilt, and drinking as an eye-opener.
- D. Minimizes drinking, frequently misses family events, guilt about drinking, and amount of daily intake.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
You may also like to solve these questions
A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client's plan of care should include what priority problem?
- A. Acute confusion.
- B. Ineffective community coping.
- C. Disturbed sensory perception.
- D. Self-care deficit.
Correct Answer: A
Rationale: Acute confusion is the priority problem because it directly impacts the client's safety and functioning. In this scenario, the client is disoriented, disorganized, and confused, which can pose immediate risks to her well-being. Ineffective community coping, disturbed sensory perception, and self-care deficit are not as urgent in this situation. Ineffective community coping focuses on the client's ability to manage stress related to the community, disturbed sensory perception pertains to alterations in sensory input, and self-care deficit involves the inability to perform activities of daily living independently. While these issues may also need addressing, acute confusion takes precedence due to the immediate safety concerns it presents.
April, a 10-year-old admitted to inpatient pediatric care, has been getting more and more wound up and is losing self-control in the day room. Time-out does not appear to be an effective tool for April to engage in self-reflection. April's mother admits to putting her in time-out up to 20 times a day. The nurse recognizes that:
- A. Time-out is an important part of April's baseline discipline.
- B. Time-out is no longer an effective therapeutic measure.
- C. April enjoys time-out and acts out to get some alone time.
- D. Time-out will need to be replaced with seclusion and restraint.
Correct Answer: B
Rationale: The correct answer is B: 'Time-out is no longer an effective therapeutic measure.' In this scenario, the excessive use of time-out, up to 20 times a day, indicates that it is no longer effective in helping April self-reflect and control her behavior. Constant use of time-out without achieving the desired outcome suggests the need for alternative therapeutic interventions. Choice A is incorrect because the situation described indicates that time-out is not serving its intended purpose. Choice C is also incorrect as the behavior is not driven by a desire for alone time. Choice D is incorrect and inappropriate as seclusion and restraint should only be considered as a last resort and are not indicated based on the information provided.
When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. What action should the nurse take?
- A. Tell him to take the medication then verify the dosage at the next healthcare team meeting.
- B. Withhold the medication until the dosage can be confirmed.
- C. Inform him that he may refuse the medication and document whether or not he takes it.
- D. Explain to the client that the dosage has been changed.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is developing unit policies that will include nursing guidelines for maintaining a therapeutic milieu. Which interventions should be included when providing a therapeutic milieu in an inpatient setting?
- A. Opportunities to contribute to one's treatment plan.
- B. One-on-one dialogue sessions with the therapist.
- C. Regularly scheduled unit activities for peer interaction.
- D. Home visits to reintegrate into the family.
Correct Answer: C
Rationale: The nurse is responsible for maintaining a therapeutic milieu in an inpatient setting, which involves creating a secure and structured environment that promotes client safety and offers opportunities for clients to learn healthy coping skills. Regularly scheduled unit activities for peer interaction help foster socialization, support, and a sense of community among clients. Choices A and B are valuable interventions in mental health care but do not directly relate to creating a therapeutic milieu in an inpatient setting. Choice D, home visits, would typically occur post-discharge and focus on community reintegration, rather than maintaining a therapeutic milieu within the inpatient setting.
A client with an eating disorder tells the RN, 'I've been eating only 400 calories per day and have been taking diuretics to lose weight.' What is the RN's best response?
- A. "Your diet is very harmful and needs to be changed immediately."
- B. "It's important to monitor your calorie intake carefully."
- C. "Have you noticed any physical effects from this low-calorie diet?"
- D. "The diuretics could be causing your body to lose essential nutrients."
Correct Answer: D
Rationale: The correct response is D. By addressing the potential harm of diuretics and the low-calorie diet, the nurse effectively addresses both aspects of the client's disordered eating behavior. Choice A is too direct and does not provide information on the specific issue of diuretics. Choice B focuses solely on monitoring calorie intake without addressing the use of diuretics. Choice C inquires about physical effects but does not address the overall risks associated with diuretics and low-calorie intake.