N330
When assessing a client for a possible physical dependency on alcohol, the nurse should ask which priority question?
"How do you feel when you haven't had a drink all day?"
The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching?
"I don't need to use my walker to get to the bathroom."
A client's alcohol consumption suggests the development of a tolerance for alcohol. Which statement supports the existence of an alcohol tolerance problem?
"I have a cocktail after work, wine with dinner, and no more than 2 drinks to sleep."
The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement?
"I no longer feel that I deserve the beatings my husband inflicts on me."
The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." Which is the most helpful response by the nurse?
"What do you find difficult about this situation?"
In monitoring a client's response to disease-modifying antirheumatic drugs (DMARDs), which assessment findings would the nurse consider acceptable responses? Select all that apply.
1.Control of symptoms during periods of emotional stress 2.Normal white blood cell, platelet, and neutrophil counts 3.Radiological findings that show no progression of joint degeneration 4.An increased range of motion in the affected joints 3 months into therapy
A client with Parkinson's disease has begun therapy with levodopa/carbidopa. The nurse determines that the client understands the action of the medication if he or she verbalizes that results may not be apparent for how long?
2 to 3 weeks
A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse should tell the client that which is the first step in this 12-step program?
Admitting to having a problem
The nurse overhears the primary health care provider (PHCP) tell a client with rheumatoid arthritis that the condition needs to be treated with gold therapy. The nurse interprets that the PHCP is referring to which medication?
Auranofin
The nurse provides instructions to a client with bilateral deformities of the joints of the fingers due to rheumatoid arthritis. When providing teaching about the disease process, the nurse should inform the client that the changes are most likely due to what type of response?
Autoimmune
The nurse is providing a health promotion session to a group of teenagers and is discussing the abuse of barbiturates. The nurse should provide which information to the teenagers?
Barbiturate abuse is the cause of many drug overdose deaths.
The client diagnosed with alcoholism has been prescribed medication therapy to assist in the maintenance of sobriety. The nurse will provide the client with education focused on which medication that will most likely be prescribed?
Disulfiram
Etanercept is prescribed for a client with rheumatoid arthritis. The nurse should monitor the client for which side/adverse effect of the medication following administration?
Dyspnea
The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium?
Hypertension, changes in level of consciousness, hallucinations
Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of the medication. Which finding indicates that the client is experiencing an adverse effect?
Impaired voluntary movements
The nurse explains to a group of clients that methamphetamine abuse results in which vascular system dysfunction?
Impaired wound healing
The home care nurse is visiting a client with a diagnosis of Parkinson's disease. The client is taking benztropine mesylate orally daily. The nurse provides information to the spouse regarding the side effects of this medication and should tell the spouse to report which side effect if it occurs?
Inability to urinate
A client is admitted with an exacerbation of multiple sclerosis. The nurse is assessing the client for possible precipitating risk factors. Which factor, if reported by the client, should the nurse identify as being unrelated to the exacerbation?
Ingestion of increased fruits and vegetables
A client with multiple sclerosis is experiencing muscle weakness, spasticity, and an ataxic gait. On the basis of this information, the nurse should include which client problem in the plan of care?
Interruption in physical mobility
A client with a history of opiate abuse asks the nurse, "Why do I crave this stuff so much?" The nurse responds, knowing that the client's craving is a result of which factor?
Lack of naturally occurring endorphins
Auranofin has been prescribed for a client with rheumatoid arthritis. The nurse provides instructions to the client about the medication and tells the client to notify the primary health care provider if which occurs?
Metallic taste in the mouth
The nurse should monitor the client with a history of heroin addiction for which signs/symptoms of heroin withdrawal?
Nausea, vomiting, diarrhea, muscle aches, and diaphoresis
The clinic nurse is performing an assessment on a client with a diagnosis of rheumatoid arthritis (RA). The nurse checks for which assessment finding that is associated with RA?
Systemic symptoms such as fatigue, anorexia, and weight loss
When discussing an individual's tendency to substance abuse, the nurse should identify which assessment data as a primary biological factor?
The client has 2 family members who have abused.
A client has been on treatment for rheumatoid arthritis for 3 weeks. During the administration of etanercept, which is most important for the nurse to assess?
The white blood cell counts and platelet counts
Before giving the client the initial dose of disulfiram, what should the psychiatric home health nurse determine?
When the last alcoholic drink was consumed
An alcohol-troubled client says, "The 12 Steps of Alcoholics Anonymous (AA) meeting really upset me. I had to go for a drink after 1 hour with those people; they're fanatics!" Which statement by the nurse would be therapeutic?
"Not any 1 strategy for remaining sober is best for everyone."
Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply.
1.Monitor vital signs. 2.Provide a safe environment. 3.Address hallucinations therapeutically. 4.Provide reality orientation as appropriate.
A client with a diagnosis of question of rheumatoid arthritis (RA) is admitted to the unit. What blood tests would the nurse expect to be prescribed to confirm the diagnosis? Select all that apply.
1.Rheumatic factor 2.Antinuclear antibody (ANA) 3.Erythrocyte sedimentation rate (ESR) 4.Anticyclic citrullinated peptide antibody (anti-CCP)
The home health nurse has been discussing interventions to prevent constipation in a client with multiple sclerosis. The nurse determines that the client is using the information most effectively if the client reports which action?
Initiating a bowel movement every other day, 45 minutes after the largest meal of the day
Which statement by the client best reflects the development of an effective coping response style and effective processing of information for a hospitalized client participating in Alcoholics Anonymous (AA)?
"I'm looking forward to leaving here. I will miss all of you. So, I'm happy and I'm sad, I'm excited, and I'm scared. I know that I have to work hard to be strong and that not everyone will be as helpful as you people."
The nurse has provided instructions to a client with a diagnosis of rheumatoid arthritis about measures to protect the joints. Which statement by the client indicates a need for further instruction?
"Pain or fatigue is expected, and I should try to continue with the activity if this occurs."
A heroin-addicted client who is taking methadone hydrochloride discontinues the methadone without consulting the primary health care provider. The client says to the nurse, "I thought I didn't need the methadone after 1 year. I had a job and was even saving money. I can't believe I ruined everything." Which statement by the nurse is therapeutic?
"We need to prepare you to recognize those things that trigger you to relapse."
The nurse is planning care for the client with a neurogenic bladder caused by multiple sclerosis. The nurse plans for fluid administration of at least 2000 mL/day. Which plan would be most helpful to this client?
400 to 500 mL with each meal and 200 to 250 mL at midmorning, midafternoon, and late afternoon
The nurse is caring for a client with Parkinson's disease. Which finding about gait should the nurse expect to note in the client?
Shuffling and propulsive
A client is taking large doses of acetylsalicylic acid for rheumatoid arthritis. Which assessment findings indicate that the client is experiencing ototoxicity as a result of the medication?
Tinnitus, hearing loss, dizziness, and ataxia
A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take?
Call the nursing supervisor.
The nurse is gathering subjective and objective data from a client with a diagnosis of suspected rheumatoid arthritis (RA). The nurse would expect to note which early signs and symptoms of RA? Select all that apply.
Fatigue & morning stiffness
The nurse should monitor a client with a history of opioid abuse for which signs and symptoms associated with opioid withdrawal?
Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, diarrhea, and mydriasis
A client has been taking glucocorticoids to control rheumatoid arthritis. Which laboratory abnormality is the client at risk for as a result of taking this medication?
Increased serum glucose
A clinic nurse is performing an assessment on a client with rheumatoid arthritis who has been taking acetylsalicylic acid for the disorder. The nurse assesses the client for signs of aspirin toxicity. Which finding should alert the nurse to the possibility of toxicity?
Fever and signs of hyperventilation
A postsurgical client with a history of heavy alcohol intake has returned to the nursing unit. Which signs/symptoms of delirium tremens should the nurse plan to continuously assess for?
Fever, hypertension, changes in level of consciousness, and hallucinations
The nurse should be prepared to manage which occurrence unique to the abuse of hallucinogenic drugs?
Flashbacks
A client with multiple sclerosis tells a home health care nurse that she is having increasing difficulty in transferring from the bed to a chair. What is the initial nursing action?
Observe the client demonstrating the transfer technique.
The spouse of an alcoholic client is attending a support group and says to the group members, "It's all very well for everyone to label me an enabler, but if I didn't call him in sick at work, he'd lose his job. Where would we be then?" Which statement by the nurse co-leader would be therapeutic?
"It is a difficult situation, but do you agree that enabling creates codependency?"
he nurse is preparing to ambulate a client with Parkinson's disease who has recently been started on levodopa/carbidopa. Before performing this activity with the client, the nurse should include which most important assessment in the client's plan of care?
Postural (orthostatic) vital signs
The nurse is performing an assessment on a client being admitted with a diagnosis of alcohol dependence who reports it's been 6 hours since the last drink. The information supports which assumption about the appearance of withdrawal symptoms?
Signs may appear at any time.
Thiamine supplementation and other nutritional vitamin support measures are prescribed for clients who have been using alcohol to prevent or decrease the risk of which complication?
Wernicke-Korsakoff syndrome
A client who has rheumatoid arthritis has begun treatment with anakinra and has received the first injection. What finding would indicate that the primary health care provider should be notified and that the medication should be discontinued?
White blood cell count of 12,000 mm3 (12 × 109/L) and a temperature of 99.9º F (37.7º C)
The mental health nurse is meeting with a client who has a long history of abusing drugs. During the session the client says to the nurse, "I'm feeling much better now, and I'm ready to stop using drugs." Which response by the nurse would be therapeutic?
"Tell me what makes you feel that you are ready."
Which are the most likely characteristics of a client who abuses alcohol? Select all that apply.
1.Male gender 2.Abuses drugs as well as alcohol 3.History of at least 1 suicide attempt
A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all my primary health care provider's fault. I have done everything I've been asked to do!" Which nursing interpretation is best for this situation?
An expected coping mechanism
The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care?
Ask the client about the amount of drug use and its effect.
A client with multiple sclerosis is receiving diazepam, a centrally acting skeletal muscle relaxant. Which finding, if noted during the nursing assessment, would indicate that the client is experiencing a side/adverse effect of this medication?
Drowsiness
