ATI Bridge COPING
A nurse is assessing a client who has a history of alcohol use disorder. Which of the following questions should the nurse include to determine how the use of alcohol affects the client's psychosocial behaviors?
"Has alcohol use affected your performance at work?" Rational:Inquiring about work performance is appropriate to include in a psychosocial assessment related to substance use disorder.
A nurse is providing teaching to a client who has alcohol use disorder about Alcoholics Anonymous (AA). Which of the following client statements indicates an understanding of the program's basic concepts?
"I am powerless against my addiction to alcohol." Rational: A basic concept of AA is that the client is powerless over his addiction to alcohol and therefore needs assistance to overcome the addiction.
A nurse is caring for a client who has a history of alcohol use disorder and has been hospitalized for detoxification. The nurse enters the room and finds the client shouting in a terrified voice, "Get these bugs off of me!" Which of the following responses by the nurse is appropriate? "I'm sure that the bugs you see will not harm you." "Tell me more about the bugs that you see in your room." "I don't see any bugs, but you seem very frightened." "I do not see anything. This is part of the withdrawal process."
"I don't see any bugs, but you seem very frightened." Rational:This client is experiencing a tactile hallucination, which is common during alcohol withdrawal. This response by the nurse presents reality and shows empathy by acknowledging the client's feelings.
A nurse is discussing the manifestations of alcohol withdrawal with a client who has a history of alcohol use disorder. Which of the following client statements indicates understanding?
"I should expect tremors to start less than 24 hours after I stop drinking." Rational:Signs of withdrawal might develop within a few hours of the client's last drink of alcohol.
A nurse is reinforcing teaching about alcohol tolerance with a newly admitted client. Which of the following statements by the client indicates understanding?
"I will develop a decreased physical response to alcohol." Rational: A client can develop alcohol tolerance due to repeated exposure to the substance and can have a decreased physical response.
A nurse is assessing an adolescent client who has anorexia nervosa. Which of the following client statements is a sign of cognitive distortion? "I like to cut my food into small pieces." "I really need to get into shape." "If I eat one piece of candy, I may as well eat ten." "I can't afford to gain weight."
"If I eat one piece of candy, I may as well eat ten." Rational: The client's statement is an example that displays all-or-nothing thinking, which is a form of cognitive distortion.
A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?
"In my dreams, all I can see are the wounded reaching out and trying to grab me." Rational:Many clients who have PTSD repeatedly re-experience the ordeal in the form of flashback episodes, memories, nightmares, or frightening thoughts, especially when they are exposed to events or objects reminiscent of the trauma. This client's statement about haunting dreams is typical of a client who has PTSD.
A nurse is teaching a group of clients about St. John's wort. Which of the following information should the nurse include in the teaching? "St. John's wort can be used to treat mild depression." "St. John's wort increases estrogen levels in the body." "St. John's wort can reduce the effectiveness of oral contraceptives." "St. John's wort can lower prostate-specific antigen levels."
"St. John's wort can be used to treat mild depression." Rational:The nurse should teach that St. John's wort increases the serotonin level of serotonin-enhancing antidepressants, which may place the client at risk for serotonin syndrome. Incorrect answer rationals: Soy has 2 compounds with estrogenic properties and can relieve menopausal hot flashes in clients. Milk thistle reduces the effectiveness of oral contraceptives. Saw palmetto can result in falsely low prostate-specific antigen levels, which might mean a delay in diagnosing prostate cancer in some clients.
A nurse is discussing obsessive-compulsive disorder (OCD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the underlying reason clients with OCD perform ritualistic behaviors? "The ritualistic behavior provides sexual satisfaction." "The client performs ritualistic behavior to boost self-esteem." "The ritualistic behavior temporarily relieves anxiety." "The client performs ritualistic behavior to decrease feelings of shame."
"The ritualistic behavior temporarily relieves anxiety." Rational: Clients with OCD perform ritualistic behaviors to provide a temporary relief from anxiety related to obsessions.
A nurse is caring for a client whose partner asks to speak with the nurse. The partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. Which of the following responses should the nurse make?
"What have you done in the past to cope with this issue?" Rational:This asks a relevant question and is therapeutic; it moves the discussion from a general direction to a specific focus on the partner's concerns and is open-ended.
A nurse is caring for a client who has severe manifestations of acute alcohol withdrawal. To ensure safe care, which of the following nursing actions should the nurse take? (Select all that apply.) - Administer a sedative. - Keep the lights on in the client's room. - Ambulate the client in the hallway. - Reduce unnecessary stimuli. Limit daily fluid intake.
Administer a sedative. Keep the lights on in the client's room. Reduce unnecessary stimuli. Rational:Sedatives reduce anxiety and exhaustion and prevent seizures.
A nurse in a mental health clinic is assessing a client who was brought in by her adult daughter stating that her mother has not been able to leave her home for weeks because she is afraid to be outdoors alone. The nurse should anticipate planning care for managing which of the following phobias? Xenophobia Acrophobia Mysophobia Agoraphobia
Agoraphobia Rational:Agoraphobia is an irrational fear about being in places or circumstances where the client would not have help in the event of panic or other forms of anxiety. Fear of being alone outdoors is a common example. Incorrect Answer Rationals: Mysophobia is a fear of dirt or germs. Acrophobia is a fear of heights. Xenophobia is a fear of strangers.
A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?
Albumin Rational: A low albumin is a measure of plasma proteins which reflects the nutritional condition of a client experiencing anorexia and malnutrition over an extended period of time.
A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect?
Anxiety and diaphoresis Rational: Alcohol withdrawal symptoms usually occur within hours of the client's last drink, and symptoms intensify over 1 to 3 days after the last drink. Chronic use of alcohol depresses the CNS, and when withdrawal occurs, the CNS stimulates an autonomic nervous system response. Early signs of withdrawal include anxiety, diaphoresis, irritability, mood swings, tremors, dilated pupils, tachycardia, hypertension, anorexia and insomnia. Alcohol withdrawal requires medical attention to safely manage the client and avoid death.
A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining weight. Which of the following nursing actions should the nurse take? Praise the client for looking at herself in a mirror. Ask the client to agree to talk to a nurse whenever she feels the urge to exercise. Reprimand the client about the potential damage that has occurred due to overexercising her body. Restrict the client from being weighed.
Ask the client to agree to talk to a nurse whenever she feels the urge to exercise. Rational:To promote effectiveness of treatment, the nurse should implement actions which establish trust and partnership with the client. This action should help the client view the nurse as a partner in treatment.
A nurse is planning care for a client who has generalized anxiety disorder. Which of the following intervention should the nurse implement to promote relaxation?
Assist the client in practicing meditation. Rational:Meditation is an effective technique to promote relaxation and is recommended for clients who have anxiety disorders.
A nurse is caring for an adolescent who was admitted with anorexia nervosa. Which of the following finding should the nurse expect? Diarrhea Hypertension Tachycardia Bloating
Bloating Rational:Bloating is a finding associated with anorexia nervosa. Incorrect Answer Rationals: Constipation, rather than diarrhea, is associated with anorexia nervosa. Hypotension, rather than hypertension, is associated with anorexia nervosa. Bradycardia, rather than tachycardia, is associated with anorexia nervosa.
A nurse is caring for a client who has a history of alcohol use disorder and reports bruising and frequent nosebleeds. The nurse should recognize that this client in manifesting which of the following conditions? Malnutrition Hepatitis A Diabetes Cirrhosis
Cirrhosis Rational: The nurse should recognizes this client is displaying manifestations of cirrhosis. A history of alcohol use disorder increases the client's risk of developing cirrhosis and coagulation defects are a common complication of cirrhosis.
A nurse is caring for a client who is undergoing treatment for substance use disorder. The client states that he drinks alcohol to relax because he works at least 60 hr each week in a successful law firm but has not yet received recognition for his work. The nurse should identify the client is exhibiting which of the following defense mechanisms?
Compensation RationCompensation is used to deal with a deficiency by emphasizing one's strengths. This client's excessive time at work and alcohol use are attempts to compensate for the lack of recognition by his employer.al:
A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect?
Constant worry about the undiagnosed presence of an illness. Rational:Clients who have illness anxiety disorder constantly worry about the presence of a serious illness even though medical tests do not support this concern.
A nurse is caring for a client who has been diagnosed with obsessive compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?
Decrease anxiety to a tolerable level. Rational:With OCD, obsessions give rise to anxiety, and the anxiety is then reduced by compulsive behaviors. Compulsive rituals are strengthened and maintained because they decrease the anxiety by terminating the event that gives rise to it.
A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention? Determine the presence and degree of suicidal risk. Assist the client to identify negative effects of chemical dependency. Identify support groups in the community for long-term treatment. Refer the client to a mental health care provider for evaluation and treatment.
Determine the presence and degree of suicidal risk. Rational: The nurse initially should establish the presence of suicide ideation when caring for a client who has a history of a depressive disorder, alcohol withdrawal, and recent job loss. Risk of suicide is increased in clients who have a history of depression and substance use. This is a safety issue and must be addressed immediately.
A nurse is caring for a client who is exhibiting signs of alcohol withdrawal. Which of the following medications should the nurse plan to administer?
Diazepam Rational: Diazepam is prescribed to treat the symptoms and prevent complications of alcohol withdrawal.
A nurse is caring for a client who is experiencing acute manifestations of withdrawal from alcohol. Which of the following medications should the nurse expect to administer to the client? Diazepam Acamprosate Naltrexone Disulfiram
Diazepam Rational: Diazepam, a benzodiazepine, is used to treat acute alcohol withdrawal. Diazepam helps to decrease the intensity of withdrawal, prevent seizures, and helps to stabilize vital signs. Incorrect Answer Rationals: Acamprosate is a medication which helps manage and maintain abstinence in clients following acute withdrawal. The nurse should not expect to administer acamprosate for a client who is experiencing withdrawal from alcohol. Disulfiram is a medication used to maintain alcohol abstinence in clients who have alcohol use disorder. Disulfiram is not used to treat acute manifestations of withdrawal.
A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings should the nurse expect? Hand tremors Stuporous level of consciousness Bradycardia Hypotension
Hand tremors Rational:Course tremors of the hands is an expected finding of alcohol withdrawal. Incorrect Answer Rationals: Stupor is an expected finding of alcohol intoxication rather than withdrawal. Tachycardia, rather than bradycardia, is an expected finding of alcohol withdrawal. Hypertension, rather than hypotension, is an expected finding of alcohol withdrawal.
A nurse in a hospital is caring for a client who has agoraphobia. Which of the following statements by the client indicates understanding of the goals of treatment?
I plan to sit on a park bench for a few minutes each day." Rational:Agoraphobia is fear of being in places in which help may not be available. This typically manifests as a fear of being outside alone. Therefore, the nurse should identify this statement as understanding of the goals of treatment.
A nurse is caring for a client who has just begun therapy with alprazolam to treat anxiety. The nurse should monitor the client for which of the following adverse effects of this medication?
Insomnia Rational:The nurse should monitor the client for paradoxical effects such as insomnia and excitation. If these occur, the medication should be withdrawn.
A nurse is planning care for a client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse plan to take? Prevent the client from performing compulsive behavior. Investigate what situations precipitate anxiety. Encourage avoidance of situations that increase anxiety. Teach the client that compulsive behavior is excessive.
Investigate what situations precipitate anxiety. Rational:Obsessions are recurrent, persistent, and impulsive thoughts that increase anxiety. Compulsions are repetitive behaviors performed in an attempt to decrease anxiety. The client is more likely to be able to interrupt obsessions if she is assisted to identify the types of situations or events which precipitate anxiety.
A nurse is assessing a client who has a diagnosis of conversion disorder. Which of the following is an expected finding?
Involuntary loss of a sensory function. Rational:The involuntary loss of a sensory function such as hearing or vision is a finding associated with conversion disorder.
A nurse notes a provider frequently arrives to the unit with bloodshot eyes and smells like alcohol after lunch. Which of the following actions should the nurse take?
Notify the nursing supervisor of the concerns. Rational: The nurse should notify hospital or nursing management of the concerns, and then ensure client safety. It is the responsibility of management to conduct an investigation. Client safety is the responsibility of the nurse.
A nurse is teaching a female client who is experiencing alcohol withdrawal about chlordiazepoxide. Which of the following information should the nurse include in the teaching?
Notify the provider if pregnancy is desired or suspected." Rational:Pregnancy is a contraindication to chlordiazepoxide. This medication is a pregnancy class D, indicating definite risks to a fetus.
A nurse in an emergency department is caring for a client who is experiencing acute alcohol withdrawal. Which of the following actions should the nurse take first?
Perform a neurological exam. Rational: The first action the nurse should take when using the nursing process is assessment. Performing a neurological exam is the priority intervention when using the assessment portion of the nursing process to approach client care.
A nurse is admitting a client to an alcohol abuse program. The client states, "I'm here because of my boss. It was part of my job to go to parties and drink with clients." The client's statement is an example of which of the following defense mechanisms?
Rationalization Rational:The client is demonstrating rationalization by trying to justify his alcohol use by blaming his boss.
A nurse is counseling a client for the management of anxiety. The client is consistently late for appointments and ignores household chores. The client states, "I'm just too stressed. I need someone to take care of me." The nurse identifies this behavior as an example of which of the following defense mechanisms?
Regression Rational:This is an example of regression which is the mechanism of reverting to childlike or immature behaviors.
A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?
Remain with the client. Rational:Remaining nearby the client will help to alleviate feelings of abandonment and reassures the client of his safety.
A nurse is providing care for a client who has anorexia nervosa. Which of the following nursing interventions should the nurse take?
Schedule regular weigh-in times. Rational:Treatment for anorexia nervosa is structured. The client is weighed at regularly scheduled times. The goal is to achieve 90% of ideal body weight.
A nurse is teaching a newly-admitted client about the possible physical effects of alcohol withdrawal. Which of the following manifestations should the nurse include in the teaching? (Select all that apply.)
Seizures is correct. Seizures are an expected finding of severe alcohol withdrawal. Illusions is correct. Illusions are an expected finding of alcohol withdrawal. Tremors is correct. Tremors are an expected finding of alcohol withdrawal.
A nurse in the emergency department is caring for a client who reports chest pain, headache, and shortness of breath. He continues to state, "I don't know why my wife left me." The client receives a diagnosis of anxiety. The nurse realizes the client's findings support which level of anxiety? Mild Moderate Severe Panic
Severe Rational: Chest pain, headache, shortness of breath, and focus on one particular item are all findings associated with severe anxiety. Incorrect: Mild anxiety causes mild physical symptoms, rather than chest pain and shortness of breath Moderate anxiety may cause a pounding heart, but is not associated with chest pain or the client's other presenting symptoms. Panic level of anxiety causes the client to lose touch with reality and is associated with unintelligible speech or the inability to speak.
A nurse in an acute mental health facility is caring for a client who jumps out of her chair and begins to shout angrily at the clients around her. Which of the following actions should the nurse take first? Call for assistance to place the client in restraints. Escort the client to an unlocked seclusion room. Offer the client a PRN antianxiety medication. Speak to the client calmly, giving simple directions.
Speak to the client calmly, giving simple directions. Rational:When providing care for an angry client, the nurse should first use the least restrictive intervention. Therefore, the nurse should speak to the client calmly and give her simple directions. This action might help prevent escalation of the client's angry behavior.
A nurse is caring for a client who wrecked his vehicle as a result of driving while under the influence of alcohol. He tells the nurse, "I had a few drinks after my boss fired me, but everything will work itself out in a few days.". The nurse should identify the client is exhibiting Which of the following defense mechanisms?
Suppression Rational: Suppression is voluntarily denying unpleasant thoughts and feelings. This client is refusing to think about his traffic violation, loss of his job, and loss of vehicle for a while.
A nurse is caring for a client who has schizophrenia and generalized anxiety disorder. The client has a prescription for alprazolam 0.25 mg PO every 8 hr PRN anxiety. For which of the following client statements should the nurse consider administering alprazolam?
The client states, "My heart is pounding out of my chest." Rational:Alprazolam is a benzodiazepine and is used to treat anxiety. The medication works in the central nervous system to decrease the severity of panic attacks, decrease anxiety and insomnia, and promote relaxation of muscles. Physiological symptoms of anxiety as it reaches the panic level often include tension, impatience, apprehension, increased heart and respiratory rates, confusion, feelings of impending doom, and extreme fright and horror. Expected adverse effects of alprazolam are dizziness, lightheadedness, and drowsiness. The nurse should closely monitor the client and assist the client with ambulation and self-care needs.
A nurse in a rehabilitation center is planning care for a newly admitted client who has a history of alcohol use disorder. Which of the following client goals is the highest priority?
The client's withdrawal from alcohol will be managed without complications. Rational: The greatest risk to the client is injury and adverse effects of withdrawal; therefore, this goal is the highest priority.
A nurse at a walk-in mental health clinic is assessing a client experiencing severe anxiety. The nurse should recognize the client might exhibit which of the following manifestations?
Threatening behavior Rational: The client experiencing severe anxiety can have feelings of confusion and impending doom. The client may feel the need to be aggressive and defensive, speaking with loud, rapid speech and possibly making threats and demands of others.
A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following findings should the nurse expect? Rapid speech Chills Distorted perceptual field Urinary frequency
Urinary frequency Rational:The nurse should expect the client who has moderate anxiety disorder to exhibit urinary frequency, as well as headache, backache, and insomnia. Incorrect Answer Rationals: The nurse should expect the client who has severe anxiety disorder to exhibit rapid speech. The nurse should expect the client who has a panic level of anxiety to exhibit chills and trembling. The nurse should expect the client who has severe anxiety disorder to have a distorted perceptual field.
A nurse is assessing a client who is withdrawing from alcohol. Which of the following findings should the nurse expect? (Select all that apply). Severe hypotension Visual hallucinations Hyperglycemia Insomnia Tremors
Visual hallucinations is correct. Visual and auditory hallucinations are expected findings with alcohol withdrawal. Insomnia is correct. Insomnia, restlessness, and irritability are common manifestations of alcohol withdrawal. Tremors is correct. Tremors and sweating are expected findings with alcohol withdrawal. Incorrect Answer Rationals: Severe hypotension is incorrect. Elevated blood pressure, rather than hypotension, is an expected finding with alcohol withdrawal. Hyperglycemia is incorrect. Clients undergoing alcohol withdrawal can develop hypoglycemia, rather than hyperglycemia, as a complication of this process.
A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take? Instruct the client to sit down and stop pacing. Allow the client to pace alone until physically tired. Have a staff member escort the client to her room. Walk with the client at a gradually slower pace.
Walk with the client at a gradually slower pace. Rational:When the client is experiencing increased anxiety, it is important for the nurse to remain with the client and promote a calm atmosphere. By walking with the client at a gradually slowing pace, the nurse provides gross motor activity as an anxiety outlet that helps to calm the client and demonstrates therapeutic offering of self.
A nurse is assessing an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect?
Constipation Rational: Constipation is an expected finding of anorexia nervosa due to the effects of starvation.
A nurse is caring for a client who has Wernicke-Korsakoff psychosis as a result of chronic alcohol use disorder. Which of the following interventions should the nurse anticipate? Laboratory analysis of cardiac enzymes Monitoring for the presence of esophageal varices Administration of thiamine Placing the client in protective isolation
Administration of thiamine Rational:Thiamine is administered to the client who has Wernicke-Korsakoff psychosis due to hepatic dysfunction and inadequate intake of sufficient vitamins. Incorrect Answer Rationals: Analysis of cardiac enzymes is appropriate when the client has alcoholic myopathy rather than Wernicke-Korsakoff psychosis. Monitoring for the presence of esophageal varices is appropriate for the client who has cirrhosis of the liver rather than Wernicke-Korsakoff psychosis. Placing a client in protective isolation is appropriate for the client who has leukopenia rather than Wernicke-Korsakoff psychosis.
AA mental health nurse is referring a client who has an alcohol addiction to a 12-step Alcoholics Anonymous program. The nurse should inform the client that which of the following is the basic concept of a 12-step program?
Admit life is unmanageable. Rational:The first basic concept of a 12-step program is to be powerless over one's addiction and to admit one's life is unmanageable.
A nurse is planning care for a client who has anorexia nervosa. The nurse should make which of the following client goals the priority? Attain a weight that is greater than the 75th percentile for age and height. Make positive statements about improvements in body image. Feel in control of her behavior. Identify changes within the family unit that promote the client's autonomy.
Attain a weight that is greater than the 75th percentile for age and height. Rational:When using Maslow's hierarchy of needs, the nurse should determine the priority goal is to meet the physiological need for adequate nutrition. This means working with the client to attain an increase in weight.
A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?
Identify precipitating factors for ritualistic behaviors. Rational:This is the priority intervention when taking the nursing process approach to client care.
A nurse is caring for a client who is receiving treatment for alcohol withdrawal. Which of the following findings is the highest priority?
Illusions Rational:Illusions may occur during severe alcohol withdrawal and prevent the greatest safety risk to the client, and are therefore the priority finding.
A nurse is planning care for a client who has a prescription for alprazolam. For which of the following adverse effects should the nurse plan to monitor?
Inability to recall events Rational:Alprazolam is a benzodiazepine medication used to manage anxiety and panic disorders. Anterograde amnesia, impaired recall of events that take place after dosing, is an adverse effect. Other adverse effects of benzodiazepines include central nervous system depression, anterograde amnesia, sleep-related behaviors (such as eating meals while sleeping), and paradoxical effects of excitation, euphoria, and heightened anxiety.
A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which of the following interventions should the nurse identify as the priority?
Providing for adequate hydration and rest Rational: Providing for the client's physical needs should be the nurse's priority until the client completes the detoxification phase of treatment. Rest is important for two reasons: alcohol use disrupts normal sleep patterns, and alcohol withdrawal or detoxification is often associated with increased restlessness and agitation. Restoring and maintaining fluid and electrolyte balance is another important goal during detoxification to prevent fluid and electrolyte imbalances.
A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?
Increasing feelings of anger. Rational: Increasing anger and irritability are findings associated with PTSD.
A nurse is caring for a client following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority? Reviewing the client's toxicology laboratory report Making a contract with the client for eating behavior Initiating suicide precautions Administering the Hamilton Depression Scale
Initiating suicide precautions Rational:Client safety is the nurse's priority. Therefore, the first action the nurse should take for this client is to initiate suicide precautions. Incorrect Answer Rationals: The nurse should review the client's laboratory findings. However, it is not the first action the nurse should take. The nurse should make a contract with the client regarding eating behavior. However, it is not the first action the nurse should take. The nurse should administer the Hamilton Depression Scale. However, it is not the first action the nurse should take.
A nurse is assessing the medical record of a female client who has anorexia nervosa. Which of the following findings should the nurse expect?
Low bone density Rational:The nurse should expect to find low bone density, called osteoporosis, due to low calcium intake and estrogen deficiency.
A nurse is interviewing a client during admission to an alcohol treatment center. Which of the following approaches should the nurse take? Maintain a nonjudgmental attitude. Avoid displaying an emotional response. Offer sympathetic support. Verbalize disapproval of the client's substance abuse.
Maintain a nonjudgmental attitude. Rational:When developing a therapeutic relationship with any client, including a client who has an addictive disorder, it is important that the nurse remain nonjudgmental, showing positive regard for the client as a person.
A nurse is assessing a client who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect?
Bradycardia Rational: Complications of anorexia include bradycardia and muscle wasting.
A nurse in the emergency department is creating a plan of care for a client experiencing alcohol intoxication. Which of the following interventions should the nurse plan to include? (Select all that apply). Contact the laboratory to obtain a blood sample. Prepare the client for a CT scan. Check the client's pupil reactivity. Obtain a urine specimen. Perform a developmental screening test.
Contact the laboratory to obtain a blood sample is correct. A blood sample allows for a blood alcohol level test to be performed.Prepare the client for a CT scan is correct. A CT scan or other neurological tests is performed to rule out brain injury or head trauma.Check the client's pupil reactivity is correct. Checking for pupil reactivity provides information about a client's neurological status.Obtain a urine specimen is correct. A urine specimen is needed to perform a urine toxicology screen. Incorrect Answer Rational: Perform a developmental screening test is incorrect. A developmental screening test is appropriate when needing information about a child or adolescent's maturational or developmental level.
A nurse is caring for a client in the emergency department who, 2 hr earlier, severed the tip of a finger in an accident. During the assessment, the nurse detects a strong smell of alcohol from the client's breath. For which of the following findings should the nurse assess first? Client's history of previous accidents Date of the client's last tetanus immunization Client's blood alcohol level Signs of wound infection
Date of the client's last tetanus immunization Rational:The greatest risk to this client is injury from infection with Clostridium tetani; therefore, the priority assessment the nurse should perform is to determine whether the client will require a tetanus immunization by identifying the date the client last received one. An adult should have a tetanus booster immunization every 10 years and after any severe or dirty wound.
A home-health nurse is assessing a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to accomplish which of the following?
Decrease anxiety. Rational:Repetitive, ritualistic behavior is an attempt by a client who has OCD to decrease anxiety.
A nurse manager is preparing to confront a staff nurse who is abusing alcohol. Which of the following defense mechanisms should the nurse manager expect the staff nurse to use?
Denial Rational: The nurse manger should expect denial of the alcohol use because denial is a common defense mechanism used by people who are dealing with the problems and responsibilities associated with the substance abuse behavior.
A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following characteristics are expected findings of OCD? (Select all that apply.)
Difficulty relaxing is correct. OCD causes high levels of stress and anxiety resulting in the client having difficulty relaxing. Rule-conscious behavior is correct. Clients who have OCD have increased anxiety if rules are not followed. Perfectionist behavior is correct. Clients who have OCD strive for perfection and have increased anxiety if it is not attained.
A nurse is preparing a client who has chronic anxiety for discharge from the psychiatric unit. Which of the following instructions should the nurse include in the client's discharge plan?
Identify anxiety-producing situations. Rational:Treatment for anxiety disorders includes helping the client recognize signs that her anxiety level is rising and the triggers that cause this type of reaction. The nurse should include this information so the client can limit anxiety-provoking situations or intervene early to reduce anxiety levels.
An assistive personnel (AP) contacts a nurse manager and reports that on the last shift a nurse seemed distracted and that a client reported that the nurse smelled of alcohol. The AP alleges that the nurse was drinking alcohol during the shift. Which of the following actions should the nurse manager take first?
Perform an investigation into the facts surrounding the incident. Rational: Before confronting the nurse or taking any other actions, the nurse manager should investigate the situation to determine if the allegations are true. Additionally, the nurse manager should evaluate the nurse's work performance, including the nurse's time and attendance record.
A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors? Isolate the client for a period of time. Confront the client about the senseless nature of the repetitive behaviors. Plan the client's schedule to allow time for rituals. Set strict limits on the behaviors so that the client can conform to the unit rules and schedules.
Plan the client's schedule to allow time for rituals. Rational: OCD is an anxiety disorder characterized by recurrent patterns of behavior a client feels driven to perform. This behavior can be a physical action or a mental act that is aimed at neutralizing anxiety or distress. In the initial phase of treatment, the nurse should allow adequate time for the client to perform rituals to help the client handle anxiety.
A nurse on an inpatient eating disorders unit is caring for a client who has anorexia nervosa and has a body mass index of 17.2. Which of the following actions should the nurse take? (Select all that apply.)
Provide the client with small meals frequently is correct. Clients who have anorexia generally will not consume large meals. Monitor the client's weight daily is correct. Daily weighing makes it difficult for the client to hide weight loss. Stay with the client during meals and for 1 hr afterward is correct. The nurse should offer support and encouragement at mealtimes but also monitor the client's behavior to prevent purging following food ingestion. Offer specific privileges for sustained weight gain is correct. Positive reinforcement includes rewards for improvements in eating behaviors and is an appropriate strategy for clients who have eating disorders.
A nurse is discussing the care of a client who has a conversion disorder with persistent aphasia with a newly licensed nurse. Which of the following statements should the nurse include about conversion disorder? -Conversion disorders are consciously triggered.
The condition may relapse within a year. Rational: About one-fourth of clients who have a conversion disorder will experience a relapse episode, usually within a year after the initial occurrence. - Incorrect Answer Rationals: The nurse should state that conversion disorders involve unconscious expression of mental stress into physical symptoms. The nurse should inform the newly licensed nurse that the provider should rule out any physical cause as the first part of treating the client. The nurse should inform the newly licensed nurse that clients who have a conversion disorder are often very upset over loss of functioning.
