Nokea
Which response by the nurse is most accurate?
- A. It will show up in urine tests 3 to 4 days after use.
- B. Traces may be picked up by sensitive blood tests 8 to 10 weeks later.
- C. Hair analysis can detect marijuana use more than a year before the urine test.
- D. Marijuana leaves the body within 2 hours of smoking it.
Correct Answer: B
Rationale: Marijuana metabolites can be detected in blood tests for weeks, with sensitive tests picking up traces 8 to 10 weeks after use, depending on frequency and amount used.
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When providing care for an Asian client diagnosed with mental illness, which barriers should be considered before the treatment? Select all that apply.
- A. Language
- B. Literacy
- C. Somatization of mental health symptoms
- D. Food preferences
- E. Client's tendency to give limited information
- F. Financial status
Correct Answer: A,C,E
Rationale: Language barriers, somatization, and limited disclosure are common cultural factors in Asian clients, impacting mental health treatment access.
The nurse suspects that a coworker is working while impaired. Which initial action should be taken by the nurse?
- A. Contact the Drug Enforcement Agency (DEA).
- B. Contact the nurse manager to report the incident.
- C. Confront the nurse and suggest that the nurse “get help.”
- D. File an anonymous report with the state’s board of nursing.
Correct Answer: B
Rationale: Reporting to the nurse manager (B) initiates investigation. DEA (A) is for diversion confronting (C) risks denial board reporting (D) follows manager.
The nurse is developing the plan of care for the client diagnosed with schizophrenia who is having an alcohol-induced crisis. Which specific client outcome best reflects the primary goal of crisis intervention for this client?
- A. Client will be successfully detoxified within 20 days.
- B. Client will return to his or her part-time job within 20 days.
- C. Client will state two effective coping mechanisms prior to discharge.
- D. Client will demonstrate self-administration of medications prior to discharge.
Correct Answer: B
Rationale: Returning to pre-crisis functioning like work (B) is the crisis intervention goal. Detox (A) stating coping mechanisms (C) and medication administration (D) are secondary.
The nurse is educating the client on the methadone prescribed for replacement therapy while in an outpatient treatment program for heroin addicts. The client asks how taking a pill is going to help the client stay substance-free. Which statement is the nurse’s best reply?
- A. “The methadone will give you the same high so you won’t want heroin anymore.”
- B. “The methadone will cause you to become very sick if you take heroin at the same time”
- C. “The methadone ‘replaces’ heroin in your body so you will have fewer cravings for heroin.”
- D. “The methadone causes sedation; you’ll sleep better so you can participate in your treatment.”
Correct Answer: C
Rationale: Methadone displaces heroin reducing cravings (C). It doesn’t produce a high (A) cause sickness (B) or sedate (D).
One day the client's daughter states to the nurse, 'I'm not sure my mom recognizes me.' Which response by the nurse is most therapeutic?
- A. It may be probably the beginning of the end.
- B. You're distressed that there isn't an appropriate response to you.
- C. Don't worry. The standard of care is being delivered.
- D. There will be good days and bad days. Today is a bad day.
Correct Answer: B
Rationale: Acknowledging the daughter's distress validates her emotions, fostering therapeutic communication and support.