Nokea
The nurses critique a chart entry that says, 'States, I feel unwanted." Appears to be confused.' Which statement best describes why this entry is unsatisfactory?"
- A. The nurse who made the entry failed to interpret the significance of feeling unwanted.
- B. The nurse who made the entry failed to indicate the importance of the client's statement.
- C. The nurse who made the entry failed to substantiate that the client made the quote.
- D. The nurse who made the entry failed to describe the evidence of the confused behavior.
Correct Answer: D
Rationale: Failing to describe specific behaviors supporting 'confused' makes the entry vague, reducing its clinical usefulness.
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Which nursing intervention is most beneficial for the client's spouse at this time?
- A. Suggesting that the spouse make an appointment for a physical examination
- B. Discussing modifying the amount of time the spouse devotes to care-giving
- C. Reminding the spouse of the scheduled times for visiting clients on the unit
- D. Explaining that many staff are available to care for the client
Correct Answer: B
Rationale: Modifying caregiving time reduces exhaustion, supporting the spouse's well-being while maintaining care responsibilities.
While caring for a client who is withdrawing from alcohol, the nurse must assess for what additional complication?
- A. Hypothermia
- B. Seizures
- C. Ascites
- D. Jaundice
Correct Answer: B
Rationale: Seizures are a serious complication of alcohol withdrawal, requiring vigilant monitoring due to their potential for harm.
The nurse is caring for the client who is 2 days postadmission to a medical unit and has a long history of heavy alcohol abuse. The nurse should monitor for which acute complications related to alcohol abuse? Select all that apply.
- A. Seizures
- B. Pancreatitis
- C. GI bleeding
- D. Exophthalmos
- E. Delirium tremens
Correct Answer: A ,B ,C, E
Rationale: Seizures (A) pancreatitis (B) GI bleeding (C) and delirium tremens (E) are acute risks. Exophthalmos (D) is unrelated.
The nurse correctly informs the caller that most people have which physical signs after recent marijuana use? Select all that apply.
- A. Shivering
- B. Inflamed eyes
- C. Rapid pulse
- D. Restlessness
- E. Pinpoint pupils
- F. Increased sex drive
Correct Answer: B,C,D
Rationale: Recent marijuana use commonly causes inflamed (red) eyes due to vasodilation, rapid pulse from cardiovascular stimulation, and restlessness from its psychoactive effects.
The nurse is planning care for the client receiving treatment for benzodiazepine abuse. Rank the interventions in the order that they should be implemented during the client’s course of treatment.
- A. Review lifestyle changes that will need to be made.
- B. Take vital signs.
- C. Administer lorazepam as prescribed.
- D. Emphasize personal responsibility for abstaining from substance abuse.
- E. Provide information about the symptoms of withdrawal.
- F. Encourage oral fluids.
Correct Answer: B ,C ,F, E, D, A
Rationale: VS (B) assess withdrawal lorazepam (C) reduces risks fluids (F) maintain hydration withdrawal info (E) educates responsibility (D) follows stability lifestyle changes (A) are last.