Nokea
Which nursing diagnosis would likely apply both to a patient diagnosed with schizophrenia as well as a patient diagnosed with amphetamine-induced psychosis?
- A. Powerlessness
- B. Disturbed thought processes
- C. Ineffective thermoregulation
- D. Impaired oral mucous membrane
Correct Answer: B
Rationale: Both conditions involve paranoid delusions, making disturbed thought processes appropriate.
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A patient undergoing alcohol rehabilitation decides to accept disulfiram therapy to avoid impulsively responding to drinking cues. Which information should be included in the discharge teaching for this patient?
- A. Avoid aged cheeses.
- B. Read labels of all liquid medications.
- C. Wear sunscreen and avoid bright sunlight.
- D. Maintain an adequate dietary intake of sodium.
- E. Avoid breathing fumes of paints, stains, and stripping compounds.
Correct Answer: B,E
Rationale: Disulfiram reacts with alcohol, so patients must avoid hidden alcohol sources like liquid medications and alcohol-laden fumes.
Which is an important nursing intervention when giving care to a patient withdrawing from a central nervous system (CNS) stimulant?
- A. Make physical contact by frequently touching the patient.
- B. Offer intellectual activities requiring concentration.
- C. Avoid manipulation by denying the patient's requests.
- D. Observe for depression and suicidal ideation.
Correct Answer: D
Rationale: Rebound depression is common in CNS stimulant withdrawal, requiring monitoring for suicide risk.
A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats/min. The patient shouts, 'Snakes are crawling on my bed. I've got to get out of here.' What is the most accurate assessment of the situation?
- A. The patient is attempting to obtain attention by manipulating staff.
- B. The patient may have sustained a head injury before admission.
- C. The patient has symptoms of alcohol withdrawal delirium.
- D. The patient is having a recurrence of an acute psychosis.
Correct Answer: C
Rationale: Symptoms of agitation, elevated pulse, and perceptual distortions point to alcohol withdrawal delirium, a medical emergency.
A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse plans for the delivery of an infant who presents with what related characteristic?
- A. Jaundice
- B. Dependent on alcohol
- C. Healthy but underweight
- D. Facial abnormalities and cognitive impairment
Correct Answer: D
Rationale: Fetal alcohol syndrome is the result of alcohol's inhibiting fetal development in the first trimester. The fetus of a woman who drinks that much alcohol will probably have this disorder.
Police bring a patient to the emergency department after an automobile accident. The patient is ataxic with slurred speech and mild confusion. The blood alcohol level is 400 mg/dL. Considering the relationship between behavior and blood alcohol level, which conclusion can the nurse draw?
- A. The patient rarely drinks alcohol.
- B. The patient has a high tolerance to alcohol.
- C. The patient has been treated with disulfiram.
- D. The patient has recently ingested both alcohol and sedative drugs.
Correct Answer: B
Rationale: A nontolerant drinker would be in a coma with a blood alcohol level of 400 mg/dL. The patient's ability to walk and talk suggests tolerance.