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A nurse is planning care for a client who has a history of alcohol use disorder and is experiencing withdrawal. Which of the following interventions should the nurse include in the plan?
- A. Administer disulfiram
- B. Monitor for seizures
- C. Restrict fluid intake
- D. Provide a high-protein diet
Correct Answer: B
Rationale: The correct answer is B: Monitor for seizures. During alcohol withdrawal, clients are at risk for seizures due to central nervous system hyperexcitability. Monitoring for seizures allows for prompt intervention if they occur. Administering disulfiram (A) is used to deter alcohol consumption, not for withdrawal. Restricting fluid intake (C) can worsen dehydration, while providing a high-protein diet (D) is not a priority during alcohol withdrawal.
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A nurse is caring for a client who has obsessive-compulsive disorder and engages in repeated handwashing. Which of the following actions should the nurse take?
- A. Encourage the client to stop washing hands
- B. Allow the client additional time to complete rituals
- C. Set strict time limits on compulsions
- D. Ignore the client’s compulsive behavior
Correct Answer: B
Rationale: The correct answer is B: Allow the client additional time to complete rituals. This approach is known as a harm reduction strategy in managing obsessive-compulsive disorder. By allowing the client additional time to complete rituals, the nurse can help reduce the client's anxiety and provide a sense of control. Encouraging the client to stop washing hands (A) may increase anxiety and worsen symptoms. Setting strict time limits on compulsions (C) can also increase anxiety and lead to distress. Ignoring the client's compulsive behavior (D) can be harmful as it may reinforce the behavior. It is important for the nurse to be supportive and understanding of the client's struggles while working towards more effective coping strategies.
A nurse is providing teaching to a client who has schizophrenia and is prescribed risperidone. Which of the following instructions should the nurse include?
- A. Avoid direct sunlight
- B. Rise slowly from a sitting position
- C. Take the medication on an empty stomach
- D. Expect weight loss as a side effect
Correct Answer: B
Rationale: The correct answer is B: Rise slowly from a sitting position. This instruction is crucial because risperidone can cause orthostatic hypotension, leading to dizziness or fainting when standing up quickly. By rising slowly, the client can minimize the risk of falls. Avoiding direct sunlight (A) is not directly related to risperidone use. Taking the medication on an empty stomach (C) is not necessary for risperidone. Expecting weight loss (D) is not a common side effect of risperidone; in fact, weight gain is more common.
A nurse is reviewing laboratory values for a client who has bipolar disorder and a prescription for lithium. Which of the following laboratory results places the client at risk for lithium toxicity?
- A. Calcium 9.0 mg/dL
- B. Sodium 130 mEq/L
- C. Chloride 98 mEq/L
- D. Potassium 5.0 mEq/L
Correct Answer: B
Rationale: The correct answer is B: Sodium 130 mEq/L. Low sodium levels increase the risk of lithium toxicity as lithium competes with sodium for reabsorption in the kidneys. This can lead to higher lithium levels in the bloodstream, putting the client at risk for toxicity. The other choices (A, C, D) are within normal ranges and do not directly impact lithium toxicity. Therefore, the client with low sodium levels is at the highest risk for lithium toxicity.
A nurse in a provider’s office is assessing a school-age child who has a spiral fracture. The parent of the child provides different accounts for the cause of the injury. Which of the following actions should the nurse take first?
- A. Request that the parent leaves the room while you interview the child
- B. Report suspected abuse to child protective services
- C. Ask the child how the injury occurred
- D. Determine the immediate safety needs of the child
Correct Answer: B
Rationale: Correct Answer: B. Report suspected abuse to child protective services.
Rationale: Reporting suspected abuse to child protective services is the first step to ensure the safety and well-being of the child. In cases of conflicting stories from the parent and the child, it is crucial to prioritize the child's safety. Child protective services can investigate further to determine the true cause of the injury and provide necessary support and protection for the child.
Summary of other choices:
A: Requesting the parent to leave the room may be necessary for further assessment, but ensuring the child's safety is the priority.
C: Asking the child how the injury occurred is important but should come after ensuring the child's immediate safety.
D: Determining the immediate safety needs of the child is crucial, but reporting suspected abuse takes precedence to address potential harm.
A nurse is caring for a client who has major depressive disorder. After discussing the treatment with his partner, the client verbally agrees to electroconvulsive therapy (ECT) but will not sign the consent form. Which of the following actions should the nurse take?
- A. Request that the client’s partner sign the consent form
- B. Cancel the scheduled ECT procedure
- C. Proceed with the preparation for ECT based on implied consent
- D. Inform the client about the risks of refusing the ECT
Correct Answer: B
Rationale: The correct answer is B: Cancel the scheduled ECT procedure. The nurse must prioritize the autonomy and right to informed consent of the client. Since the client has verbally agreed but will not sign the consent form, it indicates uncertainty or potential coercion. Proceeding without proper documentation could lead to legal and ethical issues. Requesting the partner to sign (A) may not be ethically sound without the client's explicit consent. Proceeding based on implied consent (C) is risky and violates the client's autonomy. Informing the client about risks (D) is important but should not override the need for proper consent. Cancelling the procedure allows time for further discussion and ensures the client's best interest.