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When planning care for a client who has ingested phencyclidine (PCP), the nurse is aware that the following is the highest priority?
- A. Client's physical needs
- B. Client's safety needs
- C. Client's psychosocial needs
- D. Client's medical needs
Correct Answer: B
Rationale: The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as the staff. Drug effects are unpredictable and prolonged, and the client may lose control easily. After safety needs are met, the client's physical, psychosocial, and medical needs can be met.
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The nurse is aware that which assessment finding is most consistent with early alcohol withdrawal?
- A. Heart rate of 120-140 beats/minute
- B. Heart rate of 50-60 beats/minute
- C. Blood pressure of 100/70 mmHg
- D. Blood pressure of 140/80 mmHg
Correct Answer: A
Rationale: Tachycardia, a heart rate of 120-140 beats/minute, is a common sign of alcohol withdrawal. Blood pressure may be labile throughout withdrawal, fluctuating at different stages. Hypertension typically occurs in early withdrawal. Hypotension, although rare during the early withdrawal stages, may occur in later stages. Hypotension is associated with cardiovascular collapse and most commonly occurs in clients who don't receive treatment. The nurse should monitor the client's vital signs carefully throughout the entire alcohol withdrawal process.
In the process of development the individual strives to maintain, protect, and enhance the integrity of the self. The nurse determines that this usually is accomplished through the use of:
- A. affective reactions
- B. withdrawal patterns
- C. ritualistic behaviors
- D. defense mechanisms
Correct Answer: D
Rationale: Defense mechanisms protect the ego by managing anxiety and maintaining self-integrity, per psychoanalytic theory.
A short-term goal for a patient with Alzheimer's disease is:
- A. improved functioning in the least restrictive environment.
- B. improved problem solving in activities of daily living.
- C. increased self-esteem and improved self-concept.
- D. regained sensory perception and cognitive function.
Correct Answer: A
Rationale: Improved functioning in a least restrictive environment is realistic and supports independence in Alzheimer's care.
A nursing instructor is preparing a presentation about key events and people that influenced the development of contemporary mental health and illness care. When describing the effects of World War II, which of the following would the instructor include?
- A. People began to view mental illness as more commonplace and acceptable.
- B. The biologic understanding of mental illness was almost fully developed.
- C. Deinstitutionalization occurred in response to the community health movement.
- D. Mental illnesses became categorized as psychoses or neuroses.
Correct Answer: A
Rationale: World War II increased awareness of mental health issues due to soldiers' psychological struggles, making mental illness more commonplace and acceptable in public perception.
A couple in counseling reports fighting with their child when they are angry with each other. This behavior typifies:
- A. coalition.
- B. indirect communication.
- C. transference.
- D. triangulation.
Correct Answer: D
Rationale: Triangulation involves a third party (the child) being drawn into a conflict between two others (the parents) as a way to manage tension.