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Which finding noted by the nurse during the postoperative assessment is most indicative of the client's alcoholism?
- A. Blood pressure is lower than normal.
- B. Pain is unrelieved with usual dosages of analgesics.
- C. The client asks for a beer.
- D. Pulse rates are slow, weak, and irregular.
Correct Answer: B
Rationale: Alcoholism can lead to tolerance, requiring higher analgesic doses for pain relief due to altered liver metabolism and receptor sensitivity.
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The client states “I go out just about every weekend and drink pretty heavily with my friends. Does that mean I’m dependent on alcohol?” Which is the best response by the nurse?
- A. “You’re not dependent on alcohol if you never drink to the point of intoxication.”
- B. “It sounds like you feel guilty about how much you drink. Tell me more about this.”
- C. “With dependence you have a strong need to drink and feel uncomfortable if you don’t.”
- D. “You could be dependent. Consuming alcohol pretty heavily every weekend is excessive.”
Correct Answer: C
Rationale: Dependence involves a compulsive need causing distress if unmet (C). Intoxication (A) or frequency (D) don’t define it and guilt (B) is irrelevant.
彼此The client who abuses marijuana reports liking the drug for its perceived effects. Which experiences if reported by the client should the nurse attribute to marijuana use? Select all that apply.
- A. Euphoria
- B. Increased energy
- C. Sexual enhancement
- D. Appetite suppression
- E. Improved fine-muscle coordination
Correct Answer: A, C
Rationale: Marijuana causes euphoria (A) and enhances sexual experience (C). It causes lethargy (not energy B) increased appetite (not suppression D) and tremors (not coordination E).
The client has been placed in involuntary seclusion. Which assessment observation best indicates to the nurse the client’s readiness to leave involuntary seclusion?
- A. The client calmly stating “I have control over my anger now.”
- B. BP is 110/64 mm Hg; P is 82 bpm and regular; R is 16 bpm and regular.
- C. Client is observed sitting in seclusion room doorway asking staff for a drink.
- D. Medical record states “Seclusion of 45 minutes resulted in improved control.”
Correct Answer: C
Rationale: Sitting in the doorway and requesting a drink (C) shows tolerance to stimuli. Statements (A) vital signs (B) and records (D) are less definitive than observed behavior.
The client is placed in seclusion for exhibiting violent behavior. Which should be the nurse’s primary goal of this seclusion?
- A. Assist the client in regaining self-control
- B. Assure the safety of the client and others
- C. Regain control over the unit’s environment
- D. Provide a consequence for the client’s behavior
Correct Answer: B
Rationale: Safety of client and others (B) is the primary seclusion goal by reducing stimuli. Self-control (A) and unit control (C) are outcomes and punishment (D) is inappropriate.
Which information is most appropriate for the nurse to tell the client about taking alprazolam (Xanax)?
- A. Avoid consuming alcohol while taking this drug.
- B. Take the medication with a full meal.
- C. This drug can cause insomnia in some people.
- D. A blood test will be required periodically.
Correct Answer: A
Rationale: Alcohol potentiates alprazolam's sedative effects, increasing the risk of respiratory depression and overdose, making this a critical instruction.