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Which action should the nurse implement first for a client experiencing alcohol withdrawal?
- A. Apply vest or extremity restraints.
- B. Give an alpha-adrenergic blocker.
- C. Provide a diet high in protein and calories.
- D. Prepare the environment to prevent self-injury.
Correct Answer: D
Rationale: The correct action for the nurse to implement first for a client experiencing alcohol withdrawal is to prepare the environment to prevent self-injury. Clients undergoing alcohol withdrawal are at risk of seizures and other symptoms that may lead to self-harm. By ensuring a safe environment, the nurse can mitigate the risk of injury. Applying restraints (Choice A) should only be considered if less restrictive measures fail, as restraints can agitate the client further. Giving an alpha-adrenergic blocker (Choice B) may be part of the treatment plan for alcohol withdrawal but is not the first action to take. Providing a diet high in protein and calories (Choice C) is important for overall health but is not the priority when addressing immediate safety concerns.
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A nurse determines that the wife of an alcoholic client is benefitting from attending an Al-Anon group when the nurse hears the wife say:
- A. I no longer feel that I deserve the meetings my husband inflicts on me.
- B. My attendance at the meetings has helped me to see that I provoke my husband's violence.
- C. I enjoy attending the meetings because they get me out of the house and away from my husband.
- D. I can tolerate my husband's destructive behaviors now that I know they are common with alcoholics.
Correct Answer: A
Rationale: Choice A is the correct answer as the statement indicates the wife understands that her husband's behavior is not her fault and is benefitting from the group support. Choice B is incorrect as it suggests self-blame rather than recognizing the husband's responsibility. Choice C is incorrect as the benefit is related to emotional support and understanding, not just getting away from the husband. Choice D is incorrect as tolerating destructive behaviors is not a healthy outcome of attending support groups.
For a female client with major depressive disorder reporting feelings of hopelessness and helplessness, what is the nurse's priority intervention?
- A. Encourage the client to join a support group.
- B. Refer the client for cognitive-behavioral therapy (CBT).
- C. Assess the client's risk for suicide.
- D. Suggest the client participate in daily exercise.
Correct Answer: C
Rationale: The correct answer is to assess the client's risk for suicide. When a client expresses feelings of hopelessness and helplessness, it indicates a high risk of self-harm or suicide. Therefore, the priority intervention should be to assess the client's safety. Encouraging the client to join a support group (choice A) may be beneficial but not the priority at this time. Referring the client for cognitive-behavioral therapy (CBT) (choice B) and suggesting daily exercise (choice D) are important interventions in managing depression but assessing the risk for suicide takes precedence due to the immediate safety concern.
The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (select one that does not apply)
- A. Purchase a gun to use for protection.
- B. Keep quiet and calm.
- C. Take a self-defense course that retaliates against the abuser with injury.
- D. Have a bag ready that has extra clothes for self and children.
Correct Answer: C
Rationale: Taking a self-defense course that retaliates against the abuser with injury can escalate the level of violence and is not recommended in a safety plan for a victim of intimate partner violence. The correct strategies include establishing a code, having a bag ready, and planning an escape route, which enhance safety without increasing the risk of harm.
A client with bipolar disorder is admitted to the psychiatric unit in a manic state. What is the most therapeutic nursing intervention?
- A. Allow the client to engage in any activity they choose.
- B. Provide a structured environment with reduced stimuli.
- C. Encourage the client to express their thoughts freely.
- D. Place the client in a room with another client for socialization.
Correct Answer: B
Rationale: During a manic state, individuals with bipolar disorder may exhibit hyperactivity, impulsivity, and reduced need for sleep. Providing a structured environment with reduced stimuli is the most therapeutic nursing intervention as it can help manage the client's excessive energy and prevent overstimulation. Choice A is incorrect as allowing the client to engage in any activity they choose may exacerbate their symptoms or lead to risky behaviors. Choice C, encouraging the client to express their thoughts freely, may not be appropriate during a manic state as it can further escalate their racing thoughts. Choice D, placing the client in a room with another client for socialization, may not be beneficial during a manic episode as it could increase stimulation and potentially lead to agitation.
The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the client's admission to the unit?
- A. Monitor appetite and observe intake during meals.
- B. Maintain safety in the client's environment.
- C. Provide ongoing, supportive contact.
- D. Encourage participation in activities.
Correct Answer: B
Rationale: The most critical intervention to implement during the first 48 hours after admitting a depressed client is to maintain safety (B). Depression increases the risk of suicide; hence ensuring a safe environment is the priority. While monitoring appetite (A), providing supportive contact (C), and encouraging participation in activities (D) are important aspects of care for a depressed client, ensuring safety takes precedence in the initial phase of admission.