Substance Abuse, Eating Disorders, Impulse Control Disorders

A client who was discharged earlier in the day returns to the nursing unit and demands acetaminophen with codeine. The client is advised that the client is no longer being treated on the unit and this medication cannot be administered. The client states, "I know where you park your cars, and you'd better watch out when you leave here tonight." What is the next step that the nurse should take? Call the police. Call the nursing supervisor. Ask the client to discuss the matter privately. Notify the client's family.

Call the police. The nurse should call the police because threatening staff is a criminal act. Nursing supervisors are not able to take the same actions as police officers to protect the staff. Asking to meet with the client privately is unsafe; the client's behavior is unpredictable, and the client could be a risk to others or self. Calling the client's family is not appropriate given the threats uttered.

The nurse is planning an eating disorder protocol for hospitalized clients experiencing bulimia and anorexia. Which elements should be included in the protocol? Select all that apply. Clients must rest within view of a staff member for one half hour to an hour after eating. Clients are not told their weight and cannot see their weight while being weighed. Clients must eat within view of a staff member. Clients may not go to the bathroom for one-half hour to an hour after eating. Clients cannot participate in any groups after admission until they gain one pound (0.5 kg).

Clients must eat within view of a staff member. Clients are not told their weight and cannot see their weight while being weighed. Clients must rest within view of a staff member for one half hour to an hour after eating. Clients may not go to the bathroom for one-half hour to an hour after eating. In hospital settings, clients are not allowed to know their weight at the time they are being weighed to decrease obsessing about weight gain. They must also eat and rest in staff view and cannot use the bathroom for a period to prevent discarding food or vomiting ingested food (purging). The rest prevents the client from exercising off the calories they just consumed. Barring clients from attending groups until they have gained weight diminishes the therapeutic value of the inpatient hospital stay.

A client with a history of cocaine abuse is receiving intravenous therapy and exits the hospital "to visit a friend." The client returns to the nursing unit 1 hour later, agitated, aggressive, combative, and reporting "chest pain." Place the nurse's actions in priority order from first to last. All options must be used.

Contact the security department. Obtain an ECG. Obtain a urine sample. Initiate a referral to obtain drug rehabilitation counseling. The nurse should first provide for safety of the client and the staff by requesting assistance from the security department. Next, the nurse should obtain an ECG because the client reports having chest pain. The nurse should then obtain a urine sample to identify if the client has been using illegal drugs. When the client is stabilized, the nurse can develop a care plan that includes treatment goals to support the respiratory and cardiovascular functions and enhance clearance of the agent and initiate a referral for treatment where access to the drug is eliminated and drug rehabilitation is provided as part of therapeutic management of clients with substance abuse and/or a drug overdose.

A nurse explains the guidelines for the unit's seclusion room to a client with an impulse control disorder. Which client statement indicates that the nurse has adequately communicated the client's rights? "When I go into seclusion, I won't be able to see my physician until I calm myself down." "If I lose my temper in the community room, I'll be locked up in the seclusion room." "Although I don't think I will, I can ask to go into seclusion, but I know you can make me go into the seclusion room." "Every time I decide that I won't attend a group meeting, I'll be put in seclusion."

"Although I don't think I will, I can ask to go into seclusion, but I know you can make me go into the seclusion room." As a proactive part of the treatment plan, clients may request to go into seclusion to prevent disruptive or destructive actions. In addition, the staff may use seclusion for a client whose behavior is out of control. A client who loses their temper can be guided by staff to modify their behavior. It's possible that this staff intervention can make the seclusion option unnecessary. When a client is placed in seclusion, a physician must perform a clinical assessment within 24 hours. Consequences of a client's decision not to attend a unit group meeting are related to what's written in the treatment plan. The client shouldn't be placed in seclusion unless the client is a danger to themselves or to others.

A community health nurse is teaching a group of parents about the exposure of a teenager's brain to drugs, alcohol, or violent videos. Which statement, if made by a parent, would show understanding of brain development and exposure? "Anger and impulsive behavior are a psychological manifestation without a physiologic component in the brain." "Exposure to drugs, alcohol, and violence has no physiologic impact on the brain." "The establishment of addictive patterns is generally established in adolescence." "At this time, the cortex is very susceptible to critical and long-lasting damage."

"At this time, the cortex is very susceptible to critical and long-lasting damage." The cortex is very susceptible to critical and long-lasting damage in the teenage years. There are no data to suggest that addictions are established in adolescence. There are documented data to support that exposure to drugs, alcohol, and violence has a physiologic impact on the brain. The limbic system is associated with anger and aggression, and therefore does have a physiologic component in the brain.

A client newly admitted to a psychiatric inpatient setting demands a soda from a staff member who tells him to wait until lunch arrives in 20 minutes. The client becomes angry, pushes over a sofa, throws an end table, and dumps a potted plant. Which goal should a nurse consider to be of primary importance? Performing an assessment for tardive dyskinesia Demonstrating control over aggressive behavior Learning to effectively express needs to staff and others Talking with the client's family about his angry feelings

Demonstrating control over aggressive behavior The client must demonstrate control over his aggressive behavior so that he won't hurt himself or others or destroy property in the hospital setting. A discussion of angry feelings with the family can occur at a later time. Performing an assessment for tardive dyskinesia isn't a priority in the situation described. If the client were taking neuroleptic medication, a baseline assessment for tardive dyskinesia would already have been performed. The client's learning of effective communication and coping skills is a later goal, but not of primary importance.

A client with alcohol dependency is started on a regimen of disulfiram. Which statement should the nurse include when teaching the client about the intended effects of the drug? Disulfiram improves the alcoholic's ability to drink limited amounts of alcohol. Disulfiram creates a nerve block so that the effects of alcohol are not felt. Disulfiram decreases the need for alcohol. Disulfiram acts to deter alcohol consumption.

Disulfiram acts to deter alcohol consumption. Disulfiram helps curb the impulsiveness of the problem drinker because disulfiram blocks the breakdown of alcohol in the blood, which produces marked discomfort, such as throbbing headache, flushing, and nausea and vomiting. Disulfiram does not decrease cravings for alcohol. No substance can improve the alcoholic's ability to drink moderately. Disulfiram does not block the effects of alcohol, unlike naloxone, which blocks the effects of opioids and can be helpful in the treatment of opioid addicts.

The nurse provides care to a client with chemical dependency. What are the primary nursing considerations for this client? Select all that apply. Teach the client to deal with life stressors through coping skills. Support the client's decision to stop substance use. Encourage the client to make restitution for the wrongs committed while using. Promote family interaction and involvement in the rehabilitation process. Encourage the client's family to take responsibility for the client.

Teach the client to deal with life stressors through coping skills. Support the client's decision to stop substance use. Promote family interaction and involvement in the rehabilitation process. Nursing consideration for clients undergoing treatment for chemical dependency would include helping the client gain new ways to cope with stressors. Nurses should give positive reinforcement for the client's decision to stop using. Making restitution may be a requirement for a 12-step program, but not all clients will choose to enter such programs. Clients must take responsibility for themselves; that need should not be assigned to family members. However, family should be encouraged to be active in the rehabilitation process.

The nurse is working with a highly culturally diverse group of mostly young adult clients who have substance abuse issues. Many clients in the group have had difficult social circumstances and experience relapses. What would be the most appropriate nursing intervention in dealing with these clients? Encourage motivation and confidence so that the clients can better deal with the triggers that cause them to repeat their behaviors. Provide reassurance that the problem will resolve itself in time. Demonstrate zero tolerance to relapse and provide a firm approach so the clients can repair character weaknesses now, while they are still young. Brainstorm and develop new coping strategies to share with the young adults weekly to keep a constant supply of options.

Encourage motivation and confidence so that the clients can better deal with the triggers that cause them to repeat their behaviors. Clients with multiple episodic occurrences of relapse are unable to adapt to the stressors in their lives and need support with this. Fostering client confidence will help clients deal with the triggers that cause them to relapse. Expressing a zero tolerance for relapse would demonstrate an authoritarian attitude, and it is incorrect to suggest that substance dependence/abuse is due to a weakness in character. Providing reassurance that the problem will resolve itself in time would not motivate change and is inaccurate. Providing the clients with more coping strategies does not support them in using the coping strategies they have already learned, and a weekly cadence would not give them time to learn and practice the new strategies.

A client diagnosed with bulimia tells the nurse she only eats excessively when upset with her best friend, and then she vomits to avoid gaining a lot of weight. What should the nurse do next? Work with the client to limit her purging. Schedule daily family therapy sessions. Enroll the client in a coping skills group. Obtain a PRN prescription for lorazepam to reduce binge eating urges.

Enroll the client in a coping skills group. Because the client eats excessively when upset, the best treatment would be a group to help her learn alternative coping skills. Trying to limit purging without controlling binging would result in weight gain and likely increase the client's purging. Daily family therapy sessions are not realistic. Taking lorazepam whenever she feels she needs to binge may temporarily calm the client, but does not address the cause of the binging and purging and will lead to drug dependence with long-term use.

In developing a plan of care for a client who has had previous episodes of angry verbal outbursts, the nurse plans to take an educational approach to the problem. Arrange the following steps the nurse should take from first to last. All options must be used.

Help the client identify triggers for anger. Assist the client to recognize the early cues of anger. Identify alternate ways to express anger. Practice with the client appropriate ways to express anger. Angry clients may not realize what makes them angry and the cues that their behavior is becoming out of control. The nurse should first help the client identify what triggered the anger. Once the cause of the anger and cues to the loss of control are discovered, the nurse should assist the client in identifying safe and appropriate alternative expressions of anger and then practice those techniques prior to facing a real anger-producing situation.

A nurse works with a client diagnosed with bulimia. What is the most appropriate long-term client goal for this client? Eat meals at home without binging or purging. Be able to eat out without binging or purging. Manage stresses in life without binging or purging. Be able to attend college without binging or purging.

Manage stresses in life without binging or purging. A successful outcome for a bulimic client is to avoid using the eating disorder as a coping measure when dealing with stress. Being able to attend college, eat at home, and eat out without binging and purging are important goals, but they do not address the primary problem of stress management and its connection to eating.

As part of a relapse prevention plan, a nurse is teaching a client about Alcoholics Anonymous (AA). Which information should the nurse include in the teaching? Members of AA help others develop defense mechanisms and provide a safe place to test them. Members of AA help others identify personal problems and offer solutions. Members of AA support each other and understand what it takes to achieve and maintain sobriety. Members of AA sympathize with each other and encourage each other as needed.

Members of AA support each other and understand what it takes to achieve and maintain sobriety. Membership in Alcoholics Anonymous is voluntary. Its rehabilitated members are available to support alcoholics and understand what is needed to achieve and maintain sobriety. The role of rehabilitated members does not include sympathizing with others abusing alcohol, identifying personal problems, or developing defense mechanisms.

A nurse is caring for an anorexic client with a nursing diagnosis of Imbalanced nutrition: less than body requirements related to dysfunctional eating patterns. Which interventions would be supportive for this client? Select all that apply. Provide small, frequent meals. Encourage the client to eat three substantial meals per day. Allow the client to determine food choices from a menu. Monitor the client during meals and for 1 hour after meals. Monitor weight gain. Encourage the client to keep a journal.

Provide small, frequent meals. Monitor weight gain. Allow the client to determine food choices from a menu. Encourage the client to keep a journal. Monitor the client during meals and for 1 hour after meals. Anorexia nervosa is an eating disorder characterized by excessive food restriction and irrational fear of gaining weight. Because the clients are engaged in self-starvation, clients with anorexia rarely can tolerate large meals three times per day. Small, frequent meals may be tolerated better, and they provide a way to gradually increase daily caloric intake. Providing appropriate food options from a determined menu and allowing the client to choose may be more successful in getting the adolescent to eat. The nurse would monitor the client's weight carefully because a client with anorexia may try to hide the weight loss. The nurse would also monitor the client during meals and for 1 hour afterward to ensure that the client consumes all of the food and does not attempt to purge. The client may be afraid to express feelings; keeping a journal can serve as an outlet for these feelings, which can assist recovery. A client with anorexia is already underweight and should not be permitted to skip meals.

An intoxicated client is admitted to the hospital for alcohol withdrawal. What should the nurse do to help the client become sober? Give the client black coffee to drink. Have the client take a cold shower. Walk the client around the unit. Provide the client with a quiet room to sleep in.

Provide the client with a quiet room to sleep in. The nurse should provide the client with a quiet room to sleep in. Alcohol is destroyed and oxidized in the body at a slow, steady rate. The rate of alcohol metabolism is not influenced by drinking black coffee, walking around the unit, or taking a cold shower. Therefore, it is best to have the client sleep off the effects of the alcohol.

The nurse provides care to a client brought to the emergency department with injuries from a motor vehicle collision. An intravenous line was established by paramedics. The client is now refusing bloodwork, and the nurse suspects the client may have been driving while intoxicated. How should the nurse best address the client? "This procedure will only take a few minutes, and at most you'll feel a quick pinch." "Can I help answer any questions about having your blood drawn?" "It is illegal to refuse bloodwork if you are suspected of driving under the influence." "If you are fearful of needles, I can take the sample from the intravenous line instead."

"Can I help answer any questions about having your blood drawn?" An open-ended statement or question is the most therapeutic response. It encourages the widest range of client responses, makes the client an active participant in the conversation, and shows the client that the nurse is interested in the client's feelings. The nurse should not make assumptions about the client's concerns. Assumptions that the client believes the procedure will take a long time or be painful, or that the client is afraid of needles, do not open the door for the volunteering of the client's reasoning. Informing the client that it is illegal to refuse blood testing for investigation of impaired driving is unwarranted, since this is the domain of law enforcement personnel, not of the nurse.

When doing discharge planning for a hospitalized client with impulse control disorder, a nurse explains how family members can participate effectively in the client's ongoing care. What instruction should the nurse include? "Persuade him to go to an emergency department and request medication." "After every explosive outburst, reevaluate and change the approach you use." "Consistently reward positive behavior and reinforce consequences of negative behavior." "Recognize initial anger symptoms as soon as possible and have him take medication."

"Consistently reward positive behavior and reinforce consequences of negative behavior." Consistency in rewarding positive behavior and reinforcing consequences of negative behavior is essential if the family is going to help the client learn to control angry feelings, outbursts, and actions. Changing the approach after every angry outburst isn't appropriate; the inconsistency of this approach isn't in the client's best interest. It's difficult for family members to recognize triggers that cause or intensify angry outbursts; attempts to do so could trigger an explosive outburst or cause negative behavior to escalate. It's inappropriate and unnecessary for a client to go to an emergency department and request medication when impulsive behavior occurs.

An adolescent has voluntarily been admitted for treatment of a relapse of anorexia nervosa. The client has a current body mass index (BMI) of 13, down from 16 since discharge 5 months ago. The caregivers are eager to begin a feeding regimen immediately. What teaching should the nurse provide to the caregivers? "Feeding may not begin until we have determined if there are electrolyte imbalances that need correction." "I have to establish the baseline weight and vital signs, and then we can discuss feeding options." "We have to be sure the client is agreeable to treatment. Until then, we just have to be patient." "I hear that you are concerned about this weight loss. We will start treatment and keep you updated."

"Feeding may not begin until we have determined if there are electrolyte imbalances that need correction." The client is at high risk for refeeding syndrome given the degree and length of time of the caloric deficit and having a BMI of less than 15 kg/m2. The nurse should teach the caregivers about the risk for serious complications occurring if electrolyte imbalances are not corrected prior to beginning to supply calories to the client. The client and caregivers can also be reassured that these imbalances can be corrected quickly, usually in less than 24 hours. The client has been admitted voluntarily, which indicates agreement to treatment. The nurse will of course discuss the options with the client, but this is not a reason to delay feeding. The baseline assessments do need to be collected, but without also knowing the electrolyte levels, it will still not be safe to begin feeding.

The client's spouse reports that the client has been taking about 800 mg of secobarbital daily, besides drinking more alcohol than usual. The spouse asks anxiously, "Do you think she will live?" Which response by the nurse is most appropriate? "This must be quite a shock. How long have you been married?" "We can only wait and see. It's too soon to tell." "Her condition is serious. You sound very worried about her." "She's very ill and may not live. Some do not pull through."

"Her condition is serious. You sound very worried about her." When a spouse asks whether a seriously ill client will live, it is best for the nurse to respond by explaining the seriousness of the client's condition and acknowledging the spouse's concern. This type of comment does not offer false hope. Telling the spouse to wait and see and that it is too soon to tell is a stereotypical statement that offers no support. Asking the spouse to describe the length of his or her relationship with the client ignores the spouse's concern and does not focus on the problem. Simply saying that the client is very ill and may not live and that some do not pull through is harsh and not supportive.

A 68-year-old client is admitted to the addiction unit after treatment in the emergency department for an overdose of oxycodone. The client's adult child calls the unit and expresses intense anger that the client is being treated as a "common street addict." The caller says their parent has severe back pain and was given that prescription by the client's healthcare provider. "My parent just accidentally took a few too many pills last night." Which reply by the nurse is most therapeutic? "Unfortunately, it's fairly common for clients with pain to increase their use of pain pills over time." "I can hear how upset you are. You sound very concerned about your parent." "It may be appropriate for your parent to be referred to a pain management program." "I understand that your parent may not have intentionally taken too many pills. This medication can cause one to forget how many have been taken."

"I can hear how upset you are. You sound very concerned about your parent." Acknowledging the client's child's feelings is the most therapeutic intervention because the child is not likely to hear the nurse's information until their anger and other feelings are addressed and subside. Then it is important to acknowledge that oxycodone, especially in older clients, can interfere with remembering how many pills were taken. It is common for clients with chronic pain to inadvertently overuse or become addicted to pain medications. Pain management programs help clients to withdraw from the offending medication and start on a multifaceted system for controlling the pain.

A client with severe osteoarthritis and decreased mobility is moved to an assisted living facility. The nurse notices that the client smells of alcohol, is slurring words, and has six wine bottles in the trash. The client tells the nurse, "Those are my other pain medicines." Which statements by the nurse are appropriate? Select all that apply. "I didn't realize that your pain was not being managed with your current medication." "It's important for me to know how many bottles of wine you drank this week." "How are you getting all this wine?" "I'm worried about the amount of wine you are drinking and its effects on your balance." "I'm calling your health care provider (HCP) to have all of us to talk about better pain control without the wine."

"I didn't realize that your pain was not being managed with your current medication." "It's important for me to know how many bottles of wine you drank this week." "I'm worried about the amount of wine you are drinking and its effects on your balance." "I'm calling your health care provider (HCP) to have all of us to talk about better pain control without the wine." Acknowledging the client's concern about pain and expressing the nurse's concern about the client's condition are important to help the client open up and gain further assessment of pain in this client. Awareness of the amount of wine consumption in a week will be helpful to guide which kind of detoxification will be needed. Notifying the healthcare provider about the situation and arranging for a joint conference are important for the client's safety and recovery.How the client is getting the wine is least important because there are so many possibilities such a weekly shopping trips in the facility van or having friends or family bring it in.

A client is brought to the psychiatric clinic by family members, who tell the admitting nurse that the client repeatedly drives while intoxicated despite their pleas for the client to stop doing so. During an interview with the nurse, which client statement most strongly supports a diagnosis of a substance use disorder? "I just drink to relax after work because I have a very stressful job." "I have been arrested for drunk driving three times, but I never had an accident." "I use drinking as a means for staying social with some friends." "I spend only half of my paycheck at the bar. My friends spend more!"

"I have been arrested for drunk driving three times, but I never had an accident." Addictive behavior that meets the criteria for a substance use disorder involves a maladaptive pattern of such use, indicated either by recurrent use in dangerous situations (for example, while driving) or by continued use despite knowledge of having a persistent or recurrent social, legal, occupational, psychological, or physical problem caused or exacerbated by use. Although additional criteria for this disorder include a need for increasing amounts of the substance to achieve intoxication, increased time and money spent on the substance, inability to fulfill role obligations, and typical withdrawal symptoms, the recurrent use of alcohol while driving is the strongest indicator in this scenario. The statement about the use of alcohol for socialization or as a means to relax do not indicate alcohol is interfering in the client's functioning and are therefore not strong indicators for addiction.

In an outpatient addiction group, a recovering client said that before her treatment, her husband drank on social occasions. "Now he drinks at home, from the time he comes home from work and drinks until he goes to bed. He says that he doesn't like me anymore and that I expect him to do more work on the house and yard. I used to ignore that stuff. I don't know what to do." In which order of priority from first to last would the nurse make the comments? All options must be used.

"I hear how confused and frustrated you are." "It can happen that as one person sobers up, the spouse deteriorates." "What have you tried to do about your husband's behaviors?" "What do you think you could do to have your husband come in for an evaluation?" The client's feelings and concerns need to be validated so she will open up more. She also should know that the changes in her husband are not unusual. It helps to know the client has tried with her husband to determine if they are appropriate or not. Then there can be a discussion about getting help for her husband so that her efforts to stay sober are not compromised.

After completing chemical detoxification and a 12-step program to treat crack addiction, a client is being prepared for discharge. Which remark by the client indicates a realistic view of the future? "If I can get into a good rehab facility, I know this will prevent me from using again." "With the support of my family and treatment, I will be able to reduce my crack use." "If I just take it one day at a time, I am sure I will never use crack again." "I know it is going to be hard and relapse is a possibility. I will need help."

"I know it is going to be hard and relapse is a possibility. I will need help." Addiction is a complex illness. Although clients wish to be hopeful and express confidence, asserting that by simply taking it "one day at a time" or by accessing a rehabilitation facility they will stop using is not facing the reality of the chronicity of the illness. Because relapse is common, a client claiming that he or she will never again use a specific substance is not facing the real challenges of the addiction. Acknowledging that help will be needed throughout the process is a realistic outlook. Although family and other supports are employed in addiction treatment, the goal is for cessation of drug use rather than just reduction.

During postprandial monitoring, a client with bulimia nervosa tells the nurse, "You can sit with me, but you're just wasting your time. After you sat with me yesterday, I was still able to purge. Today, my goal is to do it twice." What is the nurse's best response? "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat." "Don't worry. I won't allow you to purge today." "I trust you not to purge." "I need to know how and when you purge."

"I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat." This response acknowledges that the client is testing limits and that the nurse is setting them by performing postprandial monitoring to prevent self-induced emesis. Clients with bulimia nervosa need to feel in control of their diet because they feel they lack control over all other aspects of their lives. Because their therapeutic relationships with caregivers are less important to these clients than their need to purge, they don't fear betraying the nurse's trust by engaging in the activity. They commonly plot to purge and rarely share their secrets about it. An authoritarian or challenging response may trigger a power struggle between the nurse and client.

A client who has been arrested eight times in the past year for driving under the influence is admitted for alcohol treatment by judicial mandate. Which statement is most suggestive of alcohol dependence? "I never drink alone, so I don't have a problem." "I'm a family man, and my family doesn't drink." "I've been known to have a beer or two at a ballgame." "I drink just a little on rare social occasions."

"I never drink alone, so I don't have a problem." Most clients with alcohol dependence attempt to justify their alcohol consumption, or rationalize why it's not a problem. They typically state that they don't drink alone or only in social situations and that it is acceptable. Drinking on rare social occasions isn't suggestive of alcohol dependence. Just because the family doesn't drink doesn't mean the client doesn't have an alcohol dependence problem, but it isn't likely. Drinking occasionally isn't suggestive of alcohol dependence.

A 15-year-old client with anorexia nervosa has been admitted to a mental health unit. The client refuses to eat. Which statement is appropriate for the nurse to make? "You really look terrible at this weight. I hope you'll eat." "You don't have to eat." "Why do you think you're fat? You're underweight. Here — look in the mirror." "If you don't eat, it may be necessary to feed you by tube or I.V."

"If you don't eat, it may be necessary to feed you by tube or I.V." Clients with anorexia nervosa can refuse food to the point of cardiac damage. Tube feedings and I.V. infusions are ordered to prevent such damage. The nurse should inform the client in a matter-of-fact manner of the treatment options and possibilities. Saying the client doesn't have to eat doesn't tell the client about the consequences of choosing not to eat. Stating that a client is too thin won't change the client's self-image.

Which nursing statement is most effective when the nurse is trying to defuse a client's impending violent behavior? "Let's talk about what happened to make you this angry." "Do you feel you need to be alone in your room?" "The crisis team and I will escort you to the seclusion room." "This is a good time for you to play cards with me."

"Let's talk about what happened to make you this angry." In many instances, the nurse can defuse impending violence by helping the client identify and express feelings of anger and anxiety. This approach may help the client verbalize feelings rather than act on them. Close interaction with the client in a quiet activity may place the nurse at risk for injury should the client suddenly become violent. An agitated and potentially violent client shouldn't be left alone or unsupervised because the danger of acting out is too great. The client should be placed in seclusion only if other interventions fail or the client requests this. Unlocked seclusion can be helpful for some clients because this type of seclusion reduces environmental stimulation and provides a feeling of security.

The nurse is teaching a client about alcoholism. Which statement indicates that the client understands the nurse's teaching? "All of my relatives have problems with alcohol, but I'm not as bad as they are." "My children won't be affected by my drinking because I've quit." "I can't help it if I drink. I have an illness." "Now that I know I have this disease, it's up to me to decide if I'm going to take that drink."

"Now that I know I have this disease, it's up to me to decide if I'm going to take that drink." The development of alcoholism is influenced by biological, sociocultural, and environmental factors. The biological theories of alcoholism clearly identify genetic factors as a major influence on the development of alcoholism in some people. The disease concept of alcoholism permits the individual with the disease to not feel guilty about causing the illness. However, the responsibility of using alcohol is still up to the individual, who alone decides whether or not to take that drink of alcohol. Using the disease of alcoholism as an excuse to drink is a way to avoid responsibility for taking that drink. The statement that relatives have worse problems with alcohol reflects ongoing denial about alcoholism. Children of alcoholic parents are more likely to become alcoholics than are the children of nonalcoholic parents, even if raised in an alcohol-free environment.

A client tells a nurse that he drinks heavily in the evenings and would like to stop. The nurse suggests that he attend a support group, but he says, "I went to one meeting and all they did was swear and brag about how drunk they got." Which response would be best for the nurse to make? "Support group meetings vary from group to group. Have you thought about attending another group?" "Not everyone finds support groups helpful. There are other therapies available." "If you really want to stop your drinking, you'd go back to the support group whether you liked it or not." "That's too bad. I can see how you might have been turned off by the experience."

"Support group meetings vary from group to group. Have you thought about attending another group?" It would be best for the nurse to encourage support groups and encourage the client not to judge this mode of therapy on the basis of one meeting or group. It would be inappropriate at this stage to suggest that he give up on a support group and look at other therapies. Offering sympathy and making judgments about the meeting are not recommended. A judgmental, accusatory statement will not be supportive or helpful.

As a representative of the treatment team, a nurse is reviewing results of diagnostic studies with the family of an adolescent with anorexia nervosa. What explanation should the nurse give the family about the client's abnormal blood urea nitrogen (BUN) value? "The BUN is decreased because your daughter has developed hypothyroidism." "The BUN is decreased because your daughter is hypertensive." "The BUN is elevated because your daughter is dehydrated." "The BUN is elevated because your daughter has hypoglycemia."

"The BUN is elevated because your daughter is dehydrated." A client with anorexia nervosa will have an elevated BUN as a result of dehydration. A decreased BUN isn't associated with anorexia nervosa or with hypothyroidism. An elevated BUN isn't associated with hypoglycemia. A client with anorexia nervosa will have hyperglycemia related to a drastic decrease in nutritional intake. A decreased BUN value isn't associated with anorexia nervosa or with hypertension. A client with anorexia nervosa will have hypotension caused by impaired cardiac functioning.

A client with alcohol dependency is prescribed a B-complex vitamin. The client states, "Why do I need a vitamin? My appetite is just fine." Which of the following responses by the nurse is most appropriate? "Your doctor wants you to take it for at least 4 months." "The vitamin is a nutritional supplement important to your health." "The amount of vitamins in the alcohol you drink is very low." "You've been drinking alcohol and eating very little."

"The vitamin is a nutritional supplement important to your health." Stating that the vitamin is a nutritional supplement important to the client's health is the best response. The client is nutritionally depleted, and the B-complex vitamins produce a calming effect on the irritated central nervous system and prevent anemia, peripheral neuropathy, and Wernicke's encephalopathy. Although the statements about drinking alcohol and eating very little and that there is a low amount of vitamins in the alcohol consumed may be true, they fail to address the client's concerns directly and fail to provide the necessary information, as does telling the client that the doctor wants the client to take the vitamin for 4 months.

A client recovering from narcotic addiction states to the nurse, "I'm not going anymore to support group meetings. I felt out of place there." Which response by the nurse is best? "Sometimes the meetings can seem like a waste of time, but you need to attend to stay clean." "Maybe it just wasn't a good day for you. Everybody has bad days now and then." "Perhaps you weren't paying close enough attention to what they were saying." "Try attending a meeting at a different location; you may feel more comfortable there."

"Try attending a meeting at a different location; you may feel more comfortable there." Suggesting that the client try attending a meeting at a different location is a supportive, positive response and encourages the client to continue participating in treatment. Saying "Maybe it just wasn't a good day for you" or "Perhaps you weren't paying close enough attention" places blame on the client and is not helpful. The statement "Sometimes the meetings can seem like a waste of time, but you need to attend to stay clean" diminishes the importance of the self-help group and offers little support to the client.

The nurse cares for a client admitted to the emergency department after being found lying on the bathroom floor with several empty pill bottles around her. While waiting for a psychiatric consult, the nurse discovers that the client's boyfriend has recently broken up with her. Which response is most likely is to build and maintain a therapeutic relationship within the emergency department? "You will have other boyfriends." "What can I do to help while you are here?" "I know that this hurts." "Why did you try to kill yourself?"

"What can I do to help while you are here?" Using a client-centered approach to care will most effectively establish a therapeutic relationship. Minimizing the pain the client experiences because of the break-up does not acknowledge that at the present time the client is in significant distress. Asking "why" suggests that the nurse is judging the appropriateness of the actions and does not demonstrate empathy.

A client struggling with a binge eating disorder tells a nurse, "I don't know why I eat the way I do each night." What question would be most helpful for the nurse to ask this client? "Are there periods of time at night that you can't account for?" "Do you worry that bad things will happen to you?" "Have you experienced changes in your leisure activities?" "What do you do when you feel stressed or upset?"

"What do you do when you feel stressed or upset?" Asking what the client does when they feel stressed or upset is appropriate because clients with binge eating disorder commonly use eating as a distraction from unpleasant or negative feelings. Asking if a client worries that bad things will happen to them indirectly asks about their anxiety. Such a question doesn't focus on exploring the client's statement. A nurse should use a question related to being unable to account for elapsed periods of time to assess a dissociative identity disorder. Asking about a change in the client's leisure activities doesn't relate to the client's statement. This question could apply to any psychiatric disorder that alters the client's lifestyle.

The nurse is talking with a client who was diagnosed with bulimia 3 months ago. The client needs more education about the illness if she makes which comments? Select all that apply. "When I'm not bingeing and purging, I can skip that eating disorder support group." "My depression is gone, so I don't need my antidepressant any longer." "I've made a real effort to be more social and involved in activities." "I know that this illness is chronic and intermittent. I'll always have to control it." "If I start severely restricting my eating, I may be building up to a bingeing episode."

"When I'm not bingeing and purging, I can skip that eating disorder support group." "My depression is gone, so I don't need my antidepressant any longer." Not attending the support group consistently and not taking the antidepressant may lead to a relapse, and the client needs this information. Bulimia is chronic and intermittent and involves cycles of bingeing, purging, and restrictive eating. Increased socialization and activities promote healthy relationships.

A client that works as a pilot tells the nurse that they use illegal drugs for recreational purposes every weekend. Using the ethical principle of nonmaleficence to guide the nurse's interaction with the client, which is the nurse's best response? "If tested, you will lose your job." "You could easily have an error in judgement and cause a serious accident." "There's a problem with you choosing to use drugs as a way to cope with the stressors you experience." "Using drugs jeopardizes your health and you should consider quitting."

"You could easily have an error in judgement and cause a serious accident." Because the nurse's statement refers to those who could be harmed as a result of the pilot's drug use, the nurse's suggestion that the client should consider how an error in judgment could result in a serious accident reflects the principle of nonmaleficence (the obligation to do no harm). Telling the client that recreational drug use jeopardizes the client's health and decision-making ability addresses the personal danger of drug use, not the principle of nonmaleficence. Commenting that the pilot could test positive in a random drug test does not address any of the four basic ethical principles (autonomy, beneficence, nonmaleficence, and justice). Telling the client that there is a problem with their use of drugs to cope with stress reflects the principle of autonomy by addressing how the client's actions influence the rights of others.

Which statement by the nurse participating in a group confrontation of a coworker is most helpful in reducing the coworker's denial about alcohol being a problem? "Your behavior is unprofessional." "Nurses are the worst when it comes to asking for help." "You have alcohol on your breath." "As a nurse, you should have sought help earlier."

"You have alcohol on your breath." To be most helpful, the nurse should calmly and objectively present facts by saying, "You have alcohol on your breath," to help the coworker overcome denial and resistance. This statement also helps to reinforce the coworker's awareness of the problem. The other statements blame the coworker and may reinforce denial. Blaming, nagging, and yelling diminish self-esteem in the individual with a substance abuse problem who has low frustration tolerance.

A client with a diagnosis of anxiolytic withdrawal is prescribed lorazepam in daily decreasing dosages for 2 weeks. The client has been taking 60 mg diazepam daily for 8 month, but now has been taking lorazepam for 3 days. The client states she feels shaky, is having problems sleeping, and does not want to continue with lorazepam. She asks the nurse if she can stop taking the lorazepam now. What is the nurse's best response? "You need to continue the lorazepam as prescribed to ensure a slow and safe withdrawal." "I'll call your provider to ask if we can switch you back to diazepam." "You can discontinue the lorazepam because the worse symptoms of withdrawal are over." "Because your symptoms of withdrawal are minimal, you can take the lorazepam when you feel you need it."

"You need to continue the lorazepam as prescribed to ensure a slow and safe withdrawal." The nurse instructs the client to continue taking lorazepam as prescribed to ensure a safe, slow tapering withdrawal from diazepam. The other statements reflect poor nursing judgment because the client needs to follow the tapering schedule to ensure a safe withdrawal from benzodiazepine dependence. Contacting the provider to switch back to diazepam supports further dependence on the drug.

A client is entering rehabilitation for alcohol dependency as an alternative to going to jail for multiple arrests for driving under the influence. While obtaining the client's history, the nurse asks about the amount of alcohol the client consumes daily. The client responds, "I just have a few drinks with my friends after work." Which response by the nurse is most therapeutic? "I guess you just can't handle a few drinks." "That's what all the clients here say at first." "Then you should have had a designated driver for yourself." "You say you have a few drinks, but you have multiple arrests."

"You say you have a few drinks, but you have multiple arrests." The best way to intervene with a client's minimization or denial of alcohol problems is to point out the consequences of the drinking—the multiple arrests. The other responses are superficial and discount the seriousness of the client's problem.

A client ashamedly tells the nurse that he hit his wife while intoxicated and asks the nurse if his wife will ever forgive him. What is the nurse's most appropriate response? "It would depend on how much she really cares for you." "That is something you can explore in family therapy." "Perhaps you could ask her and find out." "You seem to have some feelings about hitting your wife."

"You seem to have some feelings about hitting your wife." The client is feeling remorse about hitting his wife. It is best to make a comment that will help him focus on his feelings and express them. Reflecting what the client has said is a good technique to accomplish these goals. Suggesting the client ask his wife or explore the issue in family therapy is inappropriate because it gives advice and ignores the client's underlying feelings. Saying, "It would depend on how much she really cares for you" is inappropriate because it ignores the client's feelings and reinforces the negative aspects such as the shamefulness of the behavior.

A client is having a severe reaction to cocaine and seems to have lost touch with reality. He is very suspicious of his friends who came with him and does not want to talk to the nurse. Suddenly, he yells out, "I'll kill you before I let you take me." Which comment by the nurse would be most useful to help the client reestablish his self-control and orientation? "You have no need to be concerned. You're going to be all right." "You have a temporary psychosis from taking a psychedelic. Let's watch some television while we wait for it to pass." "You have taken a drug you shouldn't have taken, and it's making you sick." "You're reacting to the cocaine you used. You're safe here in the hospital."

"You're reacting to the cocaine you used. You're safe here in the hospital." To help the client reestablish self-control and orientation, it would be best for the nurse to make a truthful statement about what is happening and to explain what to expect. Telling the client that he has no need for concern offers false assurance. It is not helpful to moralize by berating the client for what he did. A statement with technical terms that the client may not understand is futile. Television is generally contraindicated for a client suffering ill effects after using cocaine.

A client with a history of heroin addiction is admitted to the hospital intensive care unit with a diagnosis of opioid drug overdose. While talking with a nurse, the client's parent reports a plan to have his child declared legally incompetent. Which response by the nurse is most therapeutic? "Your child is ill and can't make decisions about health care and safety right now, but this situation is temporary." "I'll help you contact the hospital legal representative for help with the paperwork." "If you become the guardian, you'll be responsible for your child's finances and paying for treatment." "You don't have the right to declare your child incompetent. Your child has rights, too."

"Your child is ill and can't make decisions about health care and safety right now, but this situation is temporary." The client is temporarily unable to make decisions about health care and safety. After receiving emergency care and treatment, the client will probably be able to safely manage daily affairs. The nurse's reference to the client's constitutional rights isn't a therapeutic response. It's antagonistic to the parent's concern and could be a barrier to further nurse-parent interactions. The nurse shouldn't offer to help the client's parent contact the hospital's legal representative; a hospital's legal resources wouldn't be used to help a parent petition a court to declare a client incompetent. A guardian is responsible for making decisions about an individual's welfare and protecting civil rights. A guardian doesn't assume financial responsibility.

A client is admitted to the hospital following an inadvertent overdose with oxycodone. He reveals that he has chronic back pain that resulted from an injury on a construction site. He states, "I know I took too much oxycodone at once, but I can't live with this pain without them. You can't take them away from me." Which response by the nurse is most appropriate? "You're going to be switched from the oxycodone to methadone for long-term pain management." "Once you're tapered off the oxycodone, you will find that nonaddictive pain medicines will be enough to control your pain." "The oxycodone will be stopped tomorrow, but you'll have lorazepam to help you with the withdrawal symptoms." "Your pain will be controlled by tapering doses of oxycodone and with other pain management strategies and medicines."

"Your pain will be controlled by tapering doses of oxycodone and with other pain management strategies and medicines." Tapering doses of oxycodone, pain management strategies, and other pain control medicines are found to be the most helpful with opiate addictions resulting from chronic pain. Nonaddictive (over-the-counter) medicines alone are generally insufficient for chronic pain management. Methadone is an addictive opioid that involves substituting one addiction with another, so now clients are being detoxed off methadone as well. Lorazepam may help with anxiety during withdrawal from opiates, but it does not control the other symptoms of opiate withdrawal.

A school nurse is completing height and weight screenings. A young client appears underweight for their height and also appears to have hair loss. As the client steps on to the scale, the client begins to cry. Which nursing intervention is most appropriate? Request that the client stand backward on the scale when being weighed. Tell the client that they are thin and look fine. Inform the client that they have to gain weight. Weigh the client next month with the absent students.

Request that the client stand backward on the scale when being weighed. The most appropriate intervention is to have the client stand backward on the scale. This will cause the client less anxiety about seeing the number on the scale. Postponing the assessment of weight would put the client at risk if they are indeed underweight. The client is already showing signs of anorexia nervosa. Informing the client that they have to gain weight is not therapeutic. Telling the client that they are thin and look fine misses the opportunity for the nurse to handle the client's anxiety directly and ignores the client's symptoms.

A nurse is caring for a client with bulimia nervosa. Strict management of the client's dietary intake is necessary. Which intervention is the most important? Fill out the client's menu and make sure the client eats at least half of what is on the tray. Serve the client's menu choices in a supervised area and observe the client 1 hour after each meal. Let the client eat food brought by family, but have the client keep a strict calorie count. Let the client eat meals in private. Engage the client in social activities for at least 2 hours after each meal.

Serve the client's menu choices in a supervised area and observe the client 1 hour after each meal. Allowing the client to select food from the menu will help the client feel some sense of control. The client must eat 100% of what is selected. Remaining with the client for at least 1 hour after eating will prevent the client from purging. Bulimic clients should be allowed to eat only food provided by the dietary department.

A nurse is developing a care plan for a client with anorexia nervosa. Which action should the nurse include in the plan? Provide privacy for the client during meals. Set up a strict eating plan with the client. Restrict visits with family members until the client begins to eat. Encourage the client to exercise, to reduce anxiety.

Set up a strict eating plan with the client. Establishing a consistent eating plan and monitoring the client's weight are important for treatment of this disorder. Because control issues play a central part in anorexia nervosa, clients are likely to be more compliant if they take part in developing the eating plan. The family should be included in the client's care. The client should be monitored during meals — not given privacy. Exercise must be limited and supervised.

A nurse is working with a client who abuses alcohol. Which fact should the nurse communicate to the client? Daily attendance at Alcoholics Anonymous (AA) meetings will cure alcoholism. For treatment to be successful, family members must participate. An alcoholic may enjoy an occasional social drink. Abstinence is the basis for successful treatment.

Abstinence is the basis for successful treatment. Attendance at AA helps some individuals maintain strict abstinence from alcohol, which is the foundation of any treatment for alcoholism. Participation in treatment by the family is beneficial to both the client and the family but isn't essential. Abstinence requires refraining from social drinking.

When assessing a client withdrawing from alcohol, the nurse notes that the client is anxious, experiencing nausea, is restless, and has a tremor when both arms are extended. What should the nurse should do next? Transfer the client to an acute care psychiatric unit. Administer a benzodiazepine as prescribed. Continue to assess the client. Move the client to a quieter room.

Administer a benzodiazepine as prescribed. The client is exhibiting signs and symptoms of withdrawal, and the nurse should administer the benzodiazepine to manage the anxiety, nausea, and restlessness and to prevent seizures. After administering the medication, the nurse will continue to assess the client and ensure the client is in a quiet environment. There is no need to transfer this client to the psychiatric unit based on the information provided.

A nurse is teaching new staff members about groups considered at highest risk for suicide. Which group should the nurse emphasize? Depressed persons, physicians, and persons living in rural areas Alcohol abusers, widows, and young married men Women, divorced persons, and substance abusers Adolescents, those in chronic pain, and persons who are unemployed

Adolescents, those in chronic pain, and persons who are unemployed Studies of those who commit suicide reveal the following high-risk groups: adolescents; those in chronic pain; persons who are unemployed; divorced, widowed, and separated persons; professionals, such as physicians, dentists, and attorneys; students; unemployed persons; persons who are depressed, delusional, or hallucinating; alcohol or substance abusers; and persons who live in urban areas. Although more women attempt suicide than men, women typically choose less lethal means and, therefore, are less likely to complete their attempts.

A client is being treated for alcoholism. After a family meeting, the client's spouse asks a nurse about ways to help the family deal with the effects of the spouse's alcoholism. The nurse should suggest that the family join which organization? Emotions Anonymous Make Today Count Alcoholics Anonymous Al-Anon

Al-Anon Al-Anon is an organization that assists family members in sharing common experiences and increasing their understanding of alcoholism. Make Today Count is a support group for people with life-threatening or chronic illnesses. Emotions Anonymous is a support group for people experiencing depression, anxiety, or similar conditions. Alcoholics Anonymous is an organization that helps alcoholics recover by using a 12-step program.

A client who lives with his spouse and two adolescent children is being treated for alcoholism. After a family meeting, the client's wife asks a nurse about ways to help the family deal with the effects of her husband's alcoholism. Which organizations should the nurse suggest that the family join? Select all that apply. Make Today Count Alcoholics Anonymous Alateen Emotions Anonymous Al-Anon

Al-Anon Alateen Al-Anon is an organization that assists family members in sharing common experiences and increasing their understanding of alcoholism and Alateen is specifically for teens whose parent is an alcoholic. Make Today Count is a support group for people with life-threatening or chronic illnesses. Emotions Anonymous is a support group for people experiencing depression, anxiety, or similar conditions. Alcoholics Anonymous is an organization that helps alcoholics recover by using a 12-step program.

An adolescent is hospitalized with anorexia nervosa. The nurse enters the client's room and finds her doing sit-ups. What should the nurse do? Wait until she finishes and ask her why she feels the need to exercise. Remind her that if she loses weight, she will lose privileges. Ask her to stop doing the sit-ups and direct her to a quiet activity. Leave the room and allow her to exercise in private.

Ask her to stop doing the sit-ups and direct her to a quiet activity. The primary goal with severe anorexia is to promote weight gain and stop starvation. This involves actively monitoring and interrupting undesirable behaviors, such as exercise, even against the client's protests. Waiting for the client to finish exercising may be polite but exacerbates weight loss as more calories are burned. Threatening future loss of privileges does not motivate a client who is in the middle of a compulsion. Active intervention is required to prevent continued weight loss.

A client is admitted to the emergency department following an overdose of barbiturates. What should the nurse do first? Place the client in the Trendelenburg position. Assess ventilation and assist ventilation as needed. Prepare to administer blood products. Monitor the blood pressure.

Assess ventilation and assist ventilation as needed. Barbiturates can cause significant respiratory depression. The nurse's first action is to immediately assess the respiratory status and assist in bag-mask-valve ventilation as needed. Monitoring the vital signs is important, but respiratory care takes precedence over the blood pressure. Without other injury, blood products are not necessary. Placing the client in the Trendelenburg position will put pressure from the abdominal contents onto the diaphragm and further impair breathing.

On admission a client reports taking disulfiram as part of their home medications. What would the nurse need to be aware of when coordinating the client's other medications? Collaborate with the doctor for vitamin B therapy. Avoid all products containing alcohol. Increase the client's fall risk if taken with antidepressants. Assess the patient for liver injury.

Avoid all products containing alcohol. To avoid severe adverse effects, the client taking disulfiram must strictly avoid alcohol and all products that contain alcohol. Vitamin B therapy isn't necessary during disulfiram therapy. Therapeutic blood levels of disulfiram can't be measured. Disulfiram does not increase the sedative effects of antidepressants.

Which condition is commonly seen in clients who abuse cocaine? Attention deficits Panic attacks Bipolar cycling Expressive aphasia

Bipolar cycling Clients who abuse cocaine experience the rapid cycling effect of excitement then severe depression. These clients don't tend to experience panic attacks, expressive aphasia, or attention deficits.

A client is admitted to the psychiatric hospital for evaluation after numerous incidents of threatening others, angry outbursts, and two episodes of hitting a coworker at the client's place of employment. The client is very anxious and tells the nurse, "I didn't mean to hit him. He made me so mad that I just couldn't help it. I hope I don't hit anyone here." To ensure a safe environment, what should the nurse do first? Put the client in a private room, and limit the client's time out of the room to when staff can be with the client. Obtain a prescription for a medication to be administered to decrease the client's anxiety and threatening behavior. Tell the client that hitting others is unacceptable behavior, and ask the client to tell a staff member when feeling angry. Let other clients know that the client has a history of hitting others so that they will not provoke the client.

Tell the client that hitting others is unacceptable behavior, and ask the client to tell a staff member when feeling angry. The nurse must clearly address behavioral expectations, such as telling the client that hitting is unacceptable, and also provide alternatives for the client, such as letting staff members know when the client begins to feel angry. Making others responsible for the client's behavior or isolating the client in a room is inappropriate because it does not include the client in managing the behavior. Although medication may be helpful, this action does not give the client responsibility for the behavior and is not warranted at this time.

Which outcome criterion is appropriate for a child diagnosed with oppositional defiant disorder? The child will verbalize needs and assert rights. The child will recognize responsibility for behaviors. The child will establish self limits and boundaries. The child will ask the nurse's permission to sleep late.

The child will recognize responsibility for behaviors. Children with oppositional defiant disorder frequently violate the rights of others. They are defiant, are disobedient, and blame others for their actions. Recognizing accountability for actions would demonstrate progress for the oppositional child.

A female client who is hospitalized for an eating disorder weighs 15 lb (6.8 kg) less than the ideal body weight. Which goal is a priority for this client? The client eats bigger meals at breakfast. The client attends all eating disorder support groups. The client reports an improved self-image. The client gains 1 lb (0.5 kg) per week.

The client gains 1 lb (0.5 kg) per week. The actual desired weight gain of 1 lb (0.5 kg) per week is the most measurable goal for the client. Attending all eating disorder support groups is a goal, but it is not as important as actual weight gain. The client can eat a larger meal at breakfast and then not eat sufficient food and over exercise for the remainder of the day. The client's improved self-image is important, but actual weight gain is again a priority.

A young adult female who was admitted to the psychiatric hospital 2 months ago with an eating disorder is being discharged. Which action indicates the client understands discharge instructions? The client returns to the same living situation as she had prior to hospitalization. The client attends a social club at her local church. The client enrolls in a health club. The client returns to the lab for routine lab tests.

The client returns to the lab for routine lab tests. The client with an eating disorder is instructed to receive regular lab tests to monitor nutritional compliance. Frequently, the living situation from before hospitalization was dysfunctional, and returning to the situation can result in recurrent health problems. Attending a social club is not a priority for the client, and enrolling in a health club could result in the client exercising excessively.

For a client with anorexia nervosa, which goal takes the highest priority? The client will identify self-perceptions about body size as unrealistic. The client will establish adequate daily nutritional intake. The client will verbalize the possible physiological consequences of self-starvation. The client will make a contract with the nurse that sets a target weight.

The client will establish adequate daily nutritional intake. According to Maslow's hierarchy of needs, all humans must first meet basic physiologic needs. Because a client with anorexia nervosa eats little or nothing, the nurse must first plan to help the client meet this basic, immediate physiological need. The nurse may give lesser priority to goals that address long-term plans, self-perception, and potential complications.

A client on the adolescent psychiatric unit was admitted with a diagnosis of body dysmorphic disorder. The client has not been able to attend school or their part-time work over the past year as a result of certain body obsessions. Recently, the client shaved the hair all over their body, claiming, "It is all growing weird." What component of therapy would be most important for the nurse to apply to this client? The client has an underlying psychosis. The client's body image is real to the client. There may be a true minor defect. The client is at high risk for suicide.

The client's body image is real to the client. The client's body image is real to the client, and it is important for the nurse to recognize this and not dismiss the client's feelings. There may be a true minor defect, but it is the perception of the client that will assist the nurse in maintaining a therapeutic and trusting relationship. The client is not psychotic or typically at a high risk for suicide.

When interviewing the parents of an injured child, which sign is the strongest indicator that child abuse may be a problem? The parents offer consistent explanations for the injury. The injury isn't consistent with the child's history or age. The family is poor and the mother and father aren't married. The parents are argumentative and demanding with personnel.

The injury isn't consistent with the child's history or age. When the child's injuries are inconsistent with the history given or if the injuries couldn't have occurred naturally or accidentally because of the child's age and developmental stage, the emergency department nurse should suspect child abuse. Consistent explanations for the injury typically don't indicate child abuse. Child abuse occurs in all socioeconomic groups. Parents may argue and be demanding because of the stress of their child's injury.

A high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and interventions, what would be the most desirable outcome? The student discusses conflicts over drug use. The student reports increased comfort with making choices. The student accepts a referral to a substance abuse counselor. The student agrees to inform the parents of the problem.

The student accepts a referral to a substance abuse counselor. All of the outcomes stated are desirable; however, the best outcome is that the student would agree to seek the assistance of a professional substance abuse counselor.

A nurse must restrain a client to ensure the safety of other clients. When using restraints, which principle is a priority? Tie restraints securely to the side rails. Have three staff members present, one to restrain each side of the client's body and one for the head. Use an organized, efficient team approach to apply and secure the restraints. Secure restraints to the bed with knots to prevent the client from escaping.

Use an organized, efficient team approach to apply and secure the restraints. Emergency department personnel should use an organized, team approach when restraining violent clients so that no one is injured in the process. The leader, located at the client's head, should take charge; four staff members are required to hold and restrain the limbs. For safety reasons, restraints should be fastened to the bed frame instead of the side rails. For quick release, loops should be used instead of knots.

During hospitalization, a client with bulimia stops purging but becomes fearful that she will gain weight. She tells the nurse, "I can't gain weight. I'm fat enough as it is. I'll be really disgusting if I get fatter." When responding to this client, which response by the nurse would be most therapeutic? Use nonjudgmental and realistic comments. Reassure her that the staff will take complete control of her eating and will prevent her from gaining weight in the hospital. Encourage her to negotiate a calorie change with the nutritionist. Explain that the calories in her prescribed diet are not enough to cause weight gain.

Use nonjudgmental and realistic comments. Using nonjudgmental, realistic comments corrects the client's misperception without challenging or disagreeing with her verbalization of her thoughts and feelings.Reassurance about weight gain misses the point and probably will be rejected.Changing calories perpetuates the need to focus on eating and weight.Emphasizing the staff's control detracts from the client's sense of responsibility and capability to heal herself.

A client is admitted to the emergency department with an elevated blood alcohol level. The authorities state he was driving on the wrong side of the road. He is transferred to the acute care unit where he awakens the next morning. His vital signs are stable, and he has a headache. What should the nurse do first when caring for this client? Help to make abstinence and sobriety worthwhile for the client. Be persistent with the client regarding the substance use. Suggest a treatment program within the client's home area. Work through personal feelings related to substance use/abuse.

Work through personal feelings related to substance use/abuse. The nurse must work through personal feelings related to substance use. Negative feelings towards individuals with substance use problems may make the nurse prejudiced against this client. Being persistent with the client regarding the substance abuse, helping to make abstinence and sobriety worthwhile for the client, and suggesting a treatment program near the client's home all are interventions that the nurse can accomplish after the initial approach to the client.

An adolescent client is being admitted with an eating disorder. Which initial assessment finding is of greatest concern for the nurse? a heart rate of 57 bpm a systolic blood pressure of 100 mm Hg a weight loss of 10% over 6 months a potassium level of 2.5 mEq/L (2.5 mmol/L)

a potassium level of 2.5 mEq/L (2.5 mmol/L) Hypokalemia can result from excessive vomiting or laxative use in clients with eating disorders. Potassium levels of 2.5 mEq/L (2.5 mmol/L) or less are considered life-threatening and in need of urgent attention. A 10% weight loss over 6 months indicates gradual rather than rapid weight loss. Depending on the client's height and exact age, a systolic blood pressure of 100 mm Hg can be with normal limits. Low heart rates are frequently seen in clients with very restricted calorie intakes. While a heart rate of 57 bpm indicates bradycardia, if there are no other signs of poor perfusion, it is not immediately life-threatening.

While teaching a group of parents whose children have Tourette syndrome, a nurse is asked about factors associated with its development. Which factor should the nurse include in the response? abnormalities in ventricular structure and function environmental factors and birth-related trauma infection and maternal alcohol use during pregnancy abnormalities in brain neurotransmitters and the caudate nucleus, and genetics

abnormalities in brain neurotransmitters and the caudate nucleus, and genetics The etiology of Tourette syndrome involves genetics and abnormalities in neurotransmission and the caudate nucleus. The ventricles in the brain, environmental factors, birth trauma, infection, and maternal alcohol use aren't factors in the development of this condition.

A child being treated for conduct disorder is the last person on the unit selected for an activity. The nurse should expect the client to demonstrate: apathy. tearfulness. aggression. withdrawal.

aggression. Studies indicate that children who are rejected by their peers are more likely to behave aggressively. Such behavior is particularly prevalent in children with conduct disorder. The client with conduct disorder isn't likely to become tearful, withdraw, or show apathy

Eighteen hours after undergoing an emergency appendectomy, a client with a reported history of social drinking displays these vital signs: temperature, 101.6° F (38.7° C); heart rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mm Hg. The client exhibits gross hand tremors and is screaming for someone to kill the bugs in the bed. The nurse should suspect: septicemia. alcohol hallucinosis. a postoperative infection. alcohol withdrawal.

alcohol withdrawal. The client's vital signs and hallucinations suggest alcohol withdrawal delirium or alcohol withdrawal syndrome. Although infection and septicemia may arise as postoperative complications, they wouldn't cause this client's signs and symptoms and would typically occur later in the postoperative course. Alcoholic hallucinosis, a rare complication of chronic alcohol abuse, is characterized by hallucinations that occur during a state of clear consciousness, typically beginning 24 hours after the last drink. Unlike the client in this scenario, the client with alcoholic hallucinosis does not have confusion or significant changes in vital signs; except in the most advanced stages, the client recognizes the hallucinations as unreal.

Which drugs may be abused because of tolerance and physiologic dependence? verapamil and chlorpromazine clozapine and amitriptyline hydrochloride alprazolam and phenobarbital lithium and divalproex

alprazolam and phenobarbital Benzodiazepines such as alprazolam and barbiturates such as phenobarbital are addictive, controlled substances. Lithium, divalproex, verapamil, chlorpromazine, clozapine, and amitriptyline aren't addictive substances.

A client is remanded by the courts for psychiatric treatment. The police record, which dates to the client's early teenage years, includes delinquency, running away, auto theft, and vandalism. The client dropped out of school at age 16 and has been living alone then. This history suggests maladaptive coping, which is associated with: obsessive-compulsive personality disorder. narcissistic personality disorder. antisocial personality disorder. borderline personality disorder.

antisocial personality disorder. This client's history of delinquency, running away from home, vandalism, and dropping out of school is characteristic of antisocial personality disorder. This maladaptive coping pattern is manifested by a disregard for societal norms of behavior and an inability to relate meaningfully to others. In borderline personality disorder, the client exhibits mood instability, poor self-image, identity disturbance, and labile affect. Obsessive-compulsive disorder is characterized by a preoccupation with impulses and thoughts that the client realizes are senseless but can't control. Narcissistic personality disorder is characterized by a pattern of self-involvement, grandiosity, and demand for constant attention.

The charge nurse works with a new nurse to implement crisis intervention strategies. Which technique would the charge nurse need to correct if used by the new nurse? attacking the client's maladaptive defenses encouraging the client to ventilate feelings including the client in finding solutions to the problem using active and flexible approaches

attacking the client's maladaptive defenses Attacking the client's defenses decreases his ability to maintain self-esteem and ego integrity. Doing so would be the least appropriate action. Rather, the nurse should carefully encourage and teach adaptive behaviors.Encouraging the client to ventilate feelings increases his awareness of his feelings and reduces tension; this technique is appropriate in crisis intervention.Including the client in finding solutions to problems helps the client regain his self-worth and communicates confidence and respect. This technique is appropriate in crisis intervention.Using active and flexible approaches helps the nurse use interventions specific to each client in a crisis situation for a healthy crisis resolution.

A client admitted for alcohol detoxification is taking disulfiram. The nurse should instruct the client to avoid ingestion of which foods and/or liquids? Select all that apply. aged cheese cough syrup beer chocolates communal wine at church

beer communal wine at church cough syrup The client who is taking disulfiram is advised to avoid all forms of alcohol including beer, communal wine at church, and cough syrup; these can trigger a serious physical reaction. Aged cheeses and chocolate are to be avoided by the client taking monoamine oxidase inhibitors.

In the emergency department, a client with facial lacerations states that the spouse beat the client with a shoe. After the lacerations are repaired, the client waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence the spouse represents. Suddenly the client's spouse arrives, shouting a desire to "finish the job." What is the first priority of the nurse who witnesses this scene? saying that the client's spouse must leave at once determining why the spouse feels so angry remaining with the client and staying calm calling a security guard and another staff member for assistance

calling a security guard and another staff member for assistance The nurse who witnesses this scene must take precautions to ensure personal as well as client safety, but shouldn't attempt to manage a physically aggressive person alone. Therefore, the first priority is to call a security guard and another staff member. After doing this, nurse should inform the spouse what is expected, speaking in concise statements and maintaining a firm but calm demeanor. This approach makes it clear that the nurse is in control and may defuse the situation until the security guard arrives. Telling the spouse to leave would probably be ineffective in the agitated and irrational state. Exploring the spouse's anger doesn't take precedence over safeguarding the client and staff.

A new nurse has transferred to the chemical dependency rehabilitation unit. Which action if performed by the new nurse would warrant the charge nurse to intervene? helping the client to express feelings confronting the client's inappropriate behaviors calling the Narcotics Anonymous group for the client enforcing unit policies

calling the Narcotics Anonymous group for the client Calling Narcotics Anonymous to tell them to expect the client is inappropriate and unnecessary because it increases the client's dependency on the nurse. It is the client's responsibility to make arrangements for attending meetings.Enforcing unit policies is an important component in establishing a therapeutic milieu.Confronting inappropriate behaviors such as manipulation and use of defense mechanisms such as projection are part of the nurse's role in drug rehabilitation.Helping the client to express feelings appropriately through the use of assertiveness techniques teaches the client appropriate interpersonal skills.

A young adult client is admitted to a psychiatric unit with a diagnosis of alcohol abuse and personality disorder. The client's mother states, "He's always in trouble, just like when he was a boy. Now he's just a bigger prankster and out of control." In view of the client's history, which intervention is most important initially? closely observing the client's behavior to establish a baseline pattern of functioning keeping the client isolated from other clients until he is better known by the staff letting the client know the staff has the authority to subdue him if he gets unruly emphasizing to the client that he will have to pay for any damage he causes

closely observing the client's behavior to establish a baseline pattern of functioning The best initial course of action when admitting a client is to observe him to establish baseline information. This assessment provides valuable information about the client's behavior and forms the basis for the plan of care. Telling the client that the staff has authority to subdue him if he gets unruly or that he will have to pay for any damage he causes is threatening and may incite or provoke trouble. Isolating a client is not recommended unless there is a very good reason for it, such as a very active, combative client who is dangerous to himself and others.

A client is brought to the hospital's emergency department by a friend, who states, "I guess he had some heroin today." The nurse should assess the client further for which manifestations? eye irritation, tinnitus, and irritation of nasal and oral mucosa decreased respirations, constricted pupils, and pallor increased heart rate, dilated pupils, and fever tremulousness, impaired coordination, increased blood pressure, and ruddy complexion

decreased respirations, constricted pupils, and pallor Common signs of heroin overdose are respiratory depression, pale or cyanotic skin and lips, pinpoint pupils, shock, cardiac arrhythmias, and seizures. Death may occur from respiratory depression and pulmonary edema. Increased heart rate, dilated pupils, and increased temperature may indicate stimulant abuse. Tremulousness, impaired coordination, increased blood pressure, and a ruddy complexion may indicate alcohol intoxication. Eye irritation, double vision, tinnitus, and irritated mucous membranes could indicate inhalant intoxication.

A client admits to using cocaine and says, "When I stop using, I feel bad." Which effect is the client most likely to describe as occurring after he stops using cocaine? flashbacks depression double vision palpitations

depression Some feelings of depression may occur after a person stops using cocaine.Palpitations, flashbacks, and double vision are not associated with cocaine withdrawal.

When developing a therapeutic relationship with the client who has withdrawn from alcohol, the nurse should first set goals with the client that involve which behaviors? delving into painful childhood experiences discussing family role responsibilities developing effective coping skills listing reasons for alcohol abuse

developing effective coping skills When developing a nurse-client relationship with this client, focusing on the development of effective coping skills to replace ineffective behaviors is an important part of treatment and helps the client stay sober. Seeking out reasons for alcohol abuse is ineffective because anything can become a reason to drink. The client will be more successful with managing family role responsibilities with maintained sobriety, aided by effective coping skills. Delving into painful childhood experiences is not an initial part of treatment.

When teaching a client with bulimia nervosa about possible complications, which condition should the nurse emphasize? lung cancer allergies hepatitis A diabetes mellitus

diabetes mellitus Bulimia nervosa can lead to many complications, including diabetes mellitus, heart disease, and hypertension. The eating disorder isn't typically associated with allergies, lung cancer, or hepatitis A.

A client recovering from a drug overdose is interacting with the nurse and recounting her exploits at numerous parties she has attended. Which action is most therapeutic? allowing the client to continue with her stories directing the conversation to realistic concerns questioning the client further about her exploits telling the client you have heard the stories before

directing the conversation to realistic concerns The nurse directs the conversation to realistic concerns or issues to decrease denial and focus on rebuilding a substance-free life. Allowing the client to continue with the stories or questioning the client further about her exploits reinforces the denial. Telling the client you have heard the stories before is nondirective. Additionally, these actions do nothing to help the client focus on rebuilding a substance-free life.

A client is brought to the emergency department after being beaten by the spouse, a prominent attorney. The client describes the spouse's upbringing as chaotic. The nurse caring for this client understands that this situation is consistent with which fact about family violence: violent behavior is a genetic trait passed from one generation to the next. domestic violence and abuse span all socioeconomic classes. violence usually results from a power struggle. open boundaries are common in violent families.

domestic violence and abuse span all socioeconomic classes. Domestic violence and abuse affect all socioeconomic classes. Closed boundaries and an imbalance of power, with one member having control over the others, are common in violent families. Although violent behavior may be passed from one generation to the next, it's a learned behavior, not a genetic trait.

The wife of a client with alcohol dependency tells the nurse, "I'm tired of making excuses for him to his boss and coworkers when he can't make it into work. I believe him every time he says he's going to quit." The nurse recognizes the wife's statement as indicating which behavior? masochism enabling helpfulness self-defeat

enabling The wife of the man with alcohol dependency is exhibiting enabling behavior when she makes excuses for her husband's absenteeism. Enabling behavior is not helpful to the client but rescues him from adverse consequences in relation to his employment. Self-defeating behavior would be evidenced by putting oneself in a position that will lead to failure. Masochistic behavior would be evidenced by the need to experience emotional or physical pain to become sexually aroused.

A nurse is caring for an adolescent female who reports amenorrhea, weight loss, and depression. Which additional assessment finding suggests that the client has an eating disorder? hyperkalemia increased blood pressure excessive and ritualized exercise oily skin

excessive and ritualized exercise A client with an eating disorder will normally exercise to excess in an effort to burn as many calories as possible. A client with an eating disorder commonly has hypokalemia, not hyperkalemia, as a result of deficient nutritional intake and output. Skin and nails become dry and brittle, and blood pressure and body temperature drop as a result of excessive weight loss.

An adolescent client is admitted to the psychiatric unit for treatment of bulimia nervosa. The nurse is assessing the client prior to initiating the prescribed cognitive behavioral therapy (CBT) treatment. The nurse notifies the healthcare provider that CBT must be postponed if the client: denies having an eating disorder and is argumentative. has a coexisting diagnosis of borderline personality disorder. exhibits evidence of a major depressive disorder and low mood. has a body mass index in the 10th percentile with recent 5 pound (2.3 kg) weight loss.

exhibits evidence of a major depressive disorder and low mood. First-line treatment for bulimia nervosa is CBT and nutritional rehabilitation. Pharmacotherapy may sometimes be included. Prior to starting CBT, the client must be medically stable and free from suicidal ideation or major depressive disorder; either condition, if present, must be treated prior to CBT. Although borderline personality disorder may complicate CBT, it is not a contraindication. Denial and other poor coping behaviors are typical in clients with eating disorders and will be addressed with CBT. A BMI in the 10th percentile is within acceptable limits, and recent weight loss is not a reason to delay CBT.

A clinic nurse is assigned to care for a suicidal client. During the preinteraction phase, what should the nurse's priority be? exploring the nurse's own feelings about suicide referring the client to a member of the clergy to discuss the moral implications of suicide assessing the client's home environment and relationships outside the hospital discussing the future with the client

exploring the nurse's own feelings about suicide The nurse's values, beliefs, and attitudes toward self-destructive behavior influence the responses to a suicidal client; such responses set the overall mood for the nurse-client relationship. Therefore, the nurse must initially explore personal feelings about suicide to avoid conveying negative feelings to the client. Assessment of the client's home environment and relationships may reveal the need for family therapy; however, conducting such an assessment isn't a nursing priority. Discussing the future and providing anticipatory guidance can help the client prepare for future stress, but this isn't a priority. Referring the client to a member of the clergy might increase the client's trust or alleviate guilt; however, it isn't the highest priority.

A client with bulimia binges twice a day. The nurse interprets these binges as most likely involving which factors for the client? eating increasing amounts of food for substantial weight gain leaving traces of food around to attract attention feelings of euphoria and gratification feeling out of control and disgusted with self

feeling out of control and disgusted with self For the client with bulimia, binges involve a loss of control that results in thoughts of self-deprecation.Binges may reduce the feelings of anxiety felt before the bingeing behavior. They are not reflective of feelings of euphoria and gratification.Binges are done secretively; the person has no desire to attract attention.Because of the purging, substantial weight gain usually does not occur. However, the client's weight may fluctuate somewhat or remain relatively stable.

For the client with a substance abuse problem, which intervention would be most helpful to aid the client in dealing with feelings and concerns related to alcohol and drugs? group sessions individual therapy recreation solitary activities

group sessions For the client with an alcohol or drug problem, group sessions are helpful in dealing with emotions and concerns about alcohol and drugs. Clients with substance abuse problems identify with each other's similar experiences and can best help each other deal with these feelings and emotions. Additionally, the members of the group are able to support and confront each other. Individual therapy is not as helpful as group sessions because group members offer peer support and confrontation when needed. Solitary activities and recreation lead to increased avoidance of the issues that must be faced and dealt with by the client. These are often areas that the client must learn to develop and manage while in recovery.

A nurse is caring for a young child who is experiencing verbal tics and motor tics such as eye blinking and protruding the tongue. Based on this assessment, which medication would the nurse consider administering? haloperidol paroxetine fluvoxamine fluoxetine

haloperidol Haloperidol is the drug of choice for treating Tourette syndrome. Fluoxetine, fluvoxamine, and paroxetine are antidepressants and are not used to treat Tourette syndrome.

A couple seeks emergency crisis intervention because one client slapped the other client repeatedly the night before. The first client who inflicted the violence reports a childhood marred by an abusive relationship with a parent. To assess for the likelihood of further violence and abuse, the nurse should determine that the first client: has moderate impulse control. trusts the spouse and supports the spouse's independence. has learned violence as an acceptable behavior. feels secure in the relationship with the spouse.

has learned violence as an acceptable behavior. Family violence is usually a learned behavior. This couple is at risk for further violence. Poor, not moderate, impulse control indicates a risk for more violence. Violent people generally are jealous and possessive and feel insecure in their relationships.

The client is in the emergency department with her boyfriend. She is just recovering from a temporary drug-induced psychosis from lysergic acid diethylamide (LSD). She is still frightened and a little suspicious. Which nursing action is most appropriate? having the boyfriend check on the client frequently placing the client next to the nursing desk. leaving the client alone until the "trip" is over having an unlicensed assistive personnel (UAP) stay with the client to decrease her fear

having an unlicensed assistive personnel (UAP) stay with the client to decrease her fear Having a UAP stay with the client provides for reassurance and safety. Being next to the nursing desk will increase stimuli and confusion. Being alone will increase the client's fears and anxiety. It is inappropriate to ask the boyfriend to provide client supervision for the nurse.

A nurse is caring for a client who is experiencing alcohol withdrawal. Which assessment finding indicates the need for an as-needed dose of chlordiazepoxide? blood pressure of 100/70 mm Hg heart rate of 50 to 60 beats/minute heart rate of 120 to 140 beats/minute blood pressure of 140/80 mm Hg

heart rate of 120 to 140 beats/minute Tachycardia, a heart rate of 120 to 140 beats/minute, is a common sign of alcohol withdrawal. This finding indicates the need for a central nervous system depressant, which may prevent progression of alcohol withdrawal. Blood pressure may be labile throughout withdrawal, fluctuating at different stages. Hypertension typically occurs in early withdrawal. Hypotension, although rare during the early withdrawal stages, may occur in later stages. Hypotension is associated with cardiovascular collapse and most commonly occurs in clients who don't receive treatment. The nurse should carefully monitor the client's vital signs throughout the entire alcohol withdrawal process.

Which nursing action is contraindicated for the client who is experiencing severe symptoms of alcohol withdrawal? using short, concrete statements monitoring intake and output helping the client walk assessing vital signs

helping the client walk Having the client who is experiencing severe symptoms of alcohol withdrawal walk is contraindicated because increased activity and stimulation may confuse the client and promote hallucinations. The client may also sustain an injury if the client has a seizure as part of the alcohol withdrawal process. The nurse should monitor intake and output to ensure fluid and electrolyte balance and hydration. The nurse should assess vital signs to assess the physiologic status of the client and the response to medications. The nurse should use short, concrete statements to decrease confusion and ambiguity.

A client is prescribed clonidine to treat alcohol withdrawal. Which assessment data will the nurse monitor for? tremors polyuria hypotension numbness and tingling

hypotension Clonidine is used as adjunctive therapy in opioid withdrawal. It is mainly used for the treatment of blood pressure, however. With treatment for alcohol withdrawal, a priority assessment should be for hypotension. Polyuria, numbness and tingling, and tremors are not common side effects of clonidine.

A nurse is caring for a client diagnosed with bulimia nervosa. The most appropriate initial goal for this client is to: control eating impulses. identify a connection between anxiety and eating behaviors. avoid shopping for large amounts of food. restrict eating to three meals per day.

identify a connection between anxiety and eating behaviors. Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. Controlling shopping for large amounts of food isn't a goal early in treatment. Managing eating impulses and replacing them with adaptive coping mechanisms can be integrated into the care plan after initially addressing stress and underlying issues. Eating three meals per day isn't a realistic goal early in treatment.

A client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, a nurse asks when the client had the last alcoholic drink. The client says that the last drink was 6 hours before admission. Based on this response, the nurse should expect early withdrawal symptoms to peak: in 1 to 2 days. after 7 days. immediately. within 2 to 7 days.

in 1 to 2 days. Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1 to 2 days later. Alcohol withdrawal delirium may occur 2 to 4 days — even up to 7 days — after the last drink.

A client with borderline personality disorder is admitted to the psychiatric unit. Initial nursing assessment reveals that the client's wrists are sutured as a result of a recent suicide attempt. Which outcome does the nurse plan for the client to achieve? diminished feelings of guilt reduced hallucinations enhanced coping skills increased self-control

increased self-control The predominant behavioral characteristic of the client with borderline personality disorder is impulsiveness, especially of a physically self-destructive sort. Therefore, the nurse would look for outcomes related to self-control for this client. This client may or may not have feelings of guilt. Borderline personality disorder does not mean the client has hallucinations. Enhancement of coping skills is always a good outcome for clients, but this is not as important as helping the client set boundaries for impulsivity.

A severely dehydrated adolescent admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. The client's history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the past month. She is 5′ 7″ (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention takes highest priority? initiating caloric and nutritional therapy as ordered monitoring vital signs and weight regularly addressing the client's low self-esteem instituting behavioral modification therapy as ordered

initiating caloric and nutritional therapy as ordered A client with anorexia nervosa is at risk for death from self-starvation. Therefore, initiating caloric and nutritional therapy takes highest priority. Behavioral modification (in which client privileges depend on weight gain) and psychotherapy (which addresses the client's low self-esteem, guilt, anxiety, and feelings of hopelessness and depression) are important aspects of care but are secondary to stabilizing the client's physical condition. Monitoring vital signs and weight is important in evaluating nutritional therapy but doesn't take precedence over providing adequate caloric intake to ensure survival.

A client who reports consuming 1 qt (1 L) of vodka daily is admitted for alcohol detoxification. The nurse anticipates the need to teach the client about which medication? clozapine thiothixene lithium carbonate lorazepam

lorazepam The best choice for preventing or treating alcohol withdrawal symptoms is lorazepam, a benzodiazepine. Benzodiazepines are cross-dependent with alcohol and possess antianxiety and anticonvulsant properties. Both heightened anxiety and seizures are associated with alcohol withdrawal. Clozapine and thiothixene are antipsychotic agents, and lithium carbonate is an antimanic agent; these drugs are not used to manage alcohol withdrawal syndrome.

A client experiencing alcohol withdrawal exhibits tremors, diaphoresis, and hyperactivity. Blood pressure is 190/87 mm Hg, and pulse is 92 bpm. Which medication should the nurse expect to administer? lorazepam haloperidol naloxone benztropine

lorazepam The nurse would most likely administer a benzodiazepine, such as lorazepam, to the client who is experiencing symptoms of alcohol withdrawal. The benzodiazepine substitutes for the alcohol to suppress withdrawal symptoms. The client experiences symptoms of withdrawal because of the "rebound phenomenon" when sedation of the central nervous system (CNS) from alcohol begins to decrease. Haloperidol is an antipsychotic and is not indicated for alcohol withdrawal symptoms. Benztropine is used to treat extrapyramidal symptoms associated with antipsychotic therapy. Naloxone is used in opioid overdose to reverse the CNS depression caused by the opioid.

A client who is experiencing alcohol withdrawal exhibits tremors, diaphoresis, and hyperactivity. Blood pressure is 190/87 mm Hg, and pulse is 92 bpm. Which medication should the nurse expect to administer? lorazepam haloperidol naloxone benztropine

lorazepam The nurse would most likely administer a benzodiazepine, such as lorazepam, to the client who is experiencing symptoms of alcohol withdrawal. The benzodiazepine substitutes for the alcohol to suppress withdrawal symptoms. The client experiences symptoms of withdrawal because of the "rebound phenomenon" when sedation of the central nervous system (CNS) from alcohol begins to decrease. Haloperidol is an antipsychotic and is not indicated for alcohol withdrawal symptoms. Benztropine is used to treat extrapyramidal symptoms associated with antipsychotic therapy. Naloxone is used in opioid overdose to reverse the CNS depression caused by the opioid.

An unemployed client, age 24, seeks help because of feelings of depression, abandonment, and lack of clarity about a life path. The client reports quitting the last five jobs because the coworkers didn't like the client. Last week, the client's partner broke up with the client after the client drove the partner's car into a tree after an argument. The client's initial diagnosis is borderline personality disorder. Which behaviors by the client threaten the nurse-client relationship? low self-esteem, strong dependency needs, and impulsiveness suspiciousness, hypervigilance, and emotional coldness insensitivity to others, sexual acting out, and violence flat affect, social withdrawal, and unusual dress

low self-esteem, strong dependency needs, and impulsiveness Borderline personality disorder is characterized by lack of self-esteem, strong dependency needs, and impulsive behavior. Instability in interpersonal relationships and mood and poor self-image are also common. Clients can't usually tolerate being alone and they express feelings of emptiness or boredom. Flat affect, social withdrawal, and unusual dress are characteristic of schizoid personality disorder. Suspiciousness, hypervigilance, and emotional coldness are seen in paranoid personality disorders. In antisocial personality disorder, clients are usually insensitive to others and act out sexually; they may also be violent.

A client admitted to the alcohol detoxification program asks the nurse if there is a medication to "stop me from wanting a drink so badly." The nurse should teach the client about: haloperidol. magnesium sulfate. chlordiazepoxide. naltrexone.

naltrexone. Naltrexone is a drug that can decrease alcoholic cravings. Chlordiazepoxide and other sedatives help reduce the symptoms of alcohol withdrawal but don't decrease cravings. Haloperidol may be given to treat clients with psychosis, severe agitation, or delirium. Magnesium sulfate and other anticonvulsant medications are only administered to treat seizures if they occur during withdrawal.

The nurse should suspect that the client taking disulfiram has ingested alcohol when the client exhibits which symptom? nausea and flushing of the face and neck fever and muscle soreness bradycardia and vertigo sore throat and muscle aches

nausea and flushing of the face and neck The client who drinks alcohol while taking disulfiram experiences sweating, flushing of the neck and face, tachycardia, hypotension, a throbbing headache, nausea and vomiting, palpitations, dyspnea, tremor, and weakness.

The parents of a 15-year-old female with a history of disordered eating are concerned about her loss of 24 lb (10.9 kg) during the previous month. The nurse tells the parents that she'll give their daughter a comprehensive examination and make appropriate referrals. Which initial referrals should the nurse make? Select all that apply. psychiatric evaluation nutritional consult toxicology evaluation gynecologic examination dental assessment

nutritional consult psychiatric evaluation A nurse must assess a client with disordered eating and create a care plan to stabilize body weight and prevent further weight loss. The nutritional consult helps determine nutritional needs to maintain body weight. A psychiatric evaluation establishes the baseline for a care plan to address the client's emotional needs, process the client's feelings and experiences, develop effective coping skills, and develop a realistic body image and positive self-image. After the adolescent's body weight stabilizes, she should have a dental assessment to identify dental problems resulting from malnutrition or purging. Although females with disordered eating may have amenorrhea, this adolescent shouldn't have a gynecologic examination unless a medical condition warrants one at a later time. She doesn't need a toxicology evaluation unless a severe substance-abuse problem is identified.

A client begins to experience alcoholic hallucinosis. After administering medication, what is the best nursing intervention? providing a quiet environment checking the client's blood pressure every 15 minutes keeping the client restrained in bed offering the client oral liquids every 30 minutes

providing a quiet environment Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment to reduce stimulation and administering ordered central nervous system depressants in dosages that control symptoms without causing oversedation. Although bed rest is indicated, restraints are unnecessary unless the client poses a danger to self or others. Also, restraints may increase agitation and make the client feel trapped and helpless when hallucinating. Offering oral liquids every 30 minutes and measuring blood pressure every 15 minutes would interrupt the client's rest. To avoid overstimulating the client, the nurse should check the client's blood pressure and offer liquids every 2 hours.

A nurse is assigned to care for a client with anorexia nervosa. During the first 48 hours of treatment, which nursing intervention is most appropriate for this client? trying to persuade the client to eat and thus restore nutritional balance providing one-on-one supervision during meals and for 1 hour afterward letting the client eat with other clients to create a normal mealtime atmosphere giving the client as much time to eat as desired

providing one-on-one supervision during meals and for 1 hour afterward Because a client with anorexia nervosa may discard food or induce vomiting in the bathroom, the nurse should provide one-on-one supervision during meals and for 1 to 2 hours afterward. Letting the client eat with other clients wouldn't be therapeutic because other clients might urge the client to eat and give this client attention for not eating. Trying to persuade the client to eat would reinforce control issues, which are central to this client's underlying psychological problem. Instead of giving the client unlimited time to eat the nurse should set limits and let the client know what is expected.

When collaborating with the health care provider (HCP) to develop a the plan of care for a child diagnosed with attention deficit hyperactivity disorder (ADHD), the treatment plan will likely include which treatments? psychostimulant medications, such as methylphenidate, and behavior modification antidepressant medications, such as imipramine, and family therapy antianxiety medications, such as buspirone, and home schooling anticonvulsant medications, such as carbamazepine, and monthly blood levels

psychostimulant medications, such as methylphenidate, and behavior modification ADHD is typically managed by psychostimulant medications, such as methylphenidate and pemoline, along with behavior modification. Antianxiety medications, such as buspirone, are not appropriate for treating ADHD. Homeschooling commonly is not a possibility because both parents work outside the home. Antidepressants, such as imipramine, are indicated for major depressive disorders and must be used with extreme caution in children because they carry the risk of suicidal thinking. Family therapy may be a part of the treatment. Anticonvulsant medications, such as carbamazepine, are not appropriate for ADHD. Also, carbamazepine levels are obtained weekly early during therapy to avoid toxicity and ascertain therapeutic levels.

A client is voluntarily admitted to a substance use disorder unit. The client admits to drinking at least 1 qt (1 L) of vodka each day and occasionally using cocaine. Several hours after admission, a nurse suspects that the client is likely experiencing early alcohol withdrawal. What assessment findings will the nurse document as evidence of alcohol withdrawal? blood pressure of 90/50 mmHg, decreased appetite, and somnolence dehydration, temperature above 101°F (38.3°C), and pruritus vomiting, watery frequent diarrhea, and pulse below 80 beats/minute pulse of 135 beats/minute, blood pressure of 160/90 mmHg, and nervousness

pulse of 135 beats/minute, blood pressure of 160/90 mmHg, and nervousness Signs of alcohol withdrawal include diaphoresis, tremors, nervousness, nausea, vomiting, malaise, increased blood pressure and pulse rate, sleep disturbance, and irritability. Dehydration and an elevated temperature may occur, but a temperature above 101°F (38.3°C) indicates an infection rather than alcohol withdrawal. Pruritus rarely occurs in alcohol withdrawal.

A client recently admitted to the hospital with sharp, substernal chest pain suddenly reports palpitations. The client ultimately admits to using cocaine 1 hour before admission. The nurse should immediately assess the client's: neurobehavioral functioning. anxiety level. pulse rate and character. level of consciousness.

pulse rate and character. Cocaine blocks reuptake of norepinephrine, epinephrine, and dopamine, causing an excess of these neurotransmitters at postsynaptic receptor sites. Consequently, the drug is likely to cause tachyarrhythmias. Although neurobehavioral deficits are common in neonates born to cocaine users, these deficits are rare in adults. As craving for the drug increases, a person who's addicted to cocaine typically experiences euphoria followed by depression, not anxiety.

A client who is a victim of domestic violence is contemplating leaving the relationship. Which assessment should be a priority for the nurse? history of previous victimization reasons for remaining in the abusive relationship readiness to leave the perpetrator and knowledge of helpful resources use of drugs or alcohol to cope with victimization

readiness to leave the perpetrator and knowledge of helpful resources Victims of domestic violence must be assessed for their readiness to leave the perpetrator and their knowledge of the resources available to them. Nurses may then provide the victims with information and options to enable them to leave when they're ready. The reasons victims remain in violent relationships are complex and can be explored at a later time. Victims may use drugs or alcohol to cope with victimization, but this isn't the priority assessment at this time. There is no evidence to suggest that previous victimization results in a person's seeking or causing abusive relationships.

A client is being given naltrexone as part of an alcohol treatment program. When the client asks the nurse to explain the intended effects of the drug, the nurse should state that the drug: treats peripheral neuropathy. reduces compulsions to drink. prevents withdrawal symptoms. manages symptoms of anxiety.

reduces compulsions to drink. The mechanism of action of naltrexone isn't fully understood. The drug blocks opiate receptors and is believed to help diminish the compulsion to drink. Naltrexone doesn't prevent withdrawal symptoms, treat peripheral neuropathy, or manage symptoms of anxiety.

An attorney who throws books and furniture around the office after losing a case is referred to the psychiatric nurse in the law firm's employee assistance program. The nurse knows that the client's behavior most likely represents the use of which defense mechanism? intellectualization projection regression reaction formation

regression An adult who throws temper tantrums such as this one is displaying regressive behavior, or behavior that is appropriate at a younger age. In projection, the client blames someone or something other than the source of the anger or frustration or pain. In reaction formation, the client acts in opposition to feelings. In intellectualization, the client over-relies on rational explanations or abstract thinking to diminish the significance of a feeling or event.

Which food should the nurse eliminate from the diet of a client in alcohol withdrawal? regular coffee orange juice eggs milk

regular coffee Regular coffee contains caffeine, which acts as a psychomotor stimulant and leads to feelings of anxiety and agitation. Serving coffee to the client may add to tremors and wakefulness. Milk, orange juice, and eggs are part of a well-balanced, high-protein diet needed by the client in alcohol withdrawal, who is nutritionally depleted.

A client brought by ambulance to the emergency department after taking an overdose of barbiturates is comatose. The nurse should assess the client for which complication? respiratory failure kidney failure cerebrovascular accident status epilepticus

respiratory failure Because barbiturates are central nervous system depressants, the nurse should be especially alert for the possibility of respiratory failure. Respiratory failure is the most likely cause of death from barbiturate overdose. Kidney failure, cerebrovascular accident, and status epilepticus are not associated with barbiturate overdose.

When planning care for a client who has ingested phencyclidine (PCP), the nurse's highest priority should be meeting the client's: safety needs. medical needs. physical needs. psychosocial needs.

safety needs. The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as those of the staff. Drug effects are unpredictable and prolonged, and the client may easily become aggressive and physically violent. After safety needs have been met, the client's physical, psychosocial, and medical needs may be addressed.

After a dose-response test, the client with an overdose of barbiturates receives pentobarbital sodium at a nonintoxicating maintenance level for 2 days and at decreasing dosages thereafter. This regimen is effective if the client does not develop which complication? seizures psychosis hypotension hypothermia

seizures Generalized seizures may occur on the 2nd or 3rd day of withdrawal from barbiturates. Without treatment, the seizures may be fatal. Psychosis is a possibility but is not fatal and will not be prevented by the pentobarbital sodium regimen. Orthostatic hypotension is possible but is unlikely to be fatal; it is also not treatable by the pentobarbital sodium regimen. Hyperthermia, rather than hypothermia, occurs during withdrawal.

Flumazenil has been ordered for a client who has overdosed on oxazepam. Before administering the medication, the nurse should be prepared for which common adverse effect? seizures anxiety shivering chest pain

seizures Seizures are the most common serious adverse effect of using flumazenil to reverse benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine overdose. Less common adverse effects include shivering, anxiety, and chest pain.

The nurse is assessing a client who has been addicted to barbiturates. Which finding warrants additional action related to the barbiturate use? diaphoresis, twitching, and sneezing drooling, fainting, and illusions suspiciousness, tachycardia, and edema sluggishness, ataxia, and irritability

sluggishness, ataxia, and irritability Typical signs and symptoms of barbiturate abuse include sluggishness, difficulty walking, and irritability. Judgment and understanding are impaired, and speech is slurred and confused. The client acts drunk as from alcohol but does not have the odor of alcohol on her breath.Although significant, the other signs and symptoms are not effects of barbiturate use.

A client walks into the clinic and tells the nurse she has run out of money for crack, has crashed, and wants something to help her feel better. Which factor is most important for the nurse to assess? loss of appetite suicidal ideation drug craving suspiciousness

suicidal ideation The nurse assesses the client for feelings of depression and suicidal ideation. After experiencing an instantaneous high from crack, a crash immediately follows, and the client has an intense craving for more crack. A crash commonly leads to a cocaine-induced depression when additional crack is unavailable. At times, the depression is so severe that users attempt suicide. Although suspiciousness, loss of appetite, and drug craving are also associated with cocaine use, they are less of a priority than suicidal ideation.

A nurse performing an assessment determines that a client with anorexia nervosa is currently unemployed and has a family history of affective disorders, obesity, and infertility. Based on this information, the nurse should monitor the client for which health concern? avoidance behavior suicide potential explosive outbursts alcohol abuse

suicide potential An unemployed client with a personal history of anorexia nervosa and a family history of affective disorders is at high risk for suicide. Although this client could be at risk for alcohol abuse, the history indicates a strong risk of depression and suicide. Avoidance behavior is characteristic of clients diagnosed with an anxiety disorder, not anorexia nervosa. Explosive outbursts are associated with posttraumatic stress disorder and impulse control disorder.

A hospitalized client craves a drink after withdrawing from alcohol. Which measure is the best way to help the client resist the urge to drink? a routine search of visitors a locked-door policy one-to-one supervision by the staff support from other alcoholic clients

support from other alcoholic clients Group support has proved more successful than individual attention from the staff in influencing positive behavior in alcoholics.Locked doors do not help clients change behavior or develop their own controls.Searching visitors is impractical and externally oriented.One-to-one supervision by staff is impractical and not as effective as a support group.

A nurse is evaluating a client for probable amphetamine overdose. Which assessment finding supports this diagnosis? hypotension tachycardia constricted pupils hot, dry skin

tachycardia Amphetamines, which are central nervous system stimulants, cause sympathetic stimulation, including hypertension, tachycardia, vasoconstriction, and hyperthermia. Hot, dry skin is seen with anticholinergic agents such as jimsonweed. Pupils will be dilated, not constricted.

The client is admitted to the hospital for alcohol detoxification. Which intervention should the nurse use? Select all that apply. explaining to the client that the symptoms of withdrawal are temporary taking vital signs placing the client in restraints as a safety measure reinforcing reality if the client is disoriented or hallucinating monitoring intake and output

taking vital signs monitoring intake and output reinforcing reality if the client is disoriented or hallucinating explaining to the client that the symptoms of withdrawal are temporary For the client experiencing symptoms of alcohol withdrawal, the nurse monitors vital signs and intake and output, reinforces reality for the client who is confused, disoriented, or hallucinating, explains that the symptoms of withdrawal are temporary, reduces stimulation, and stays with the client if he is confused or agitated. The nurse administers medications to prevent the progression of symptoms, such as seizures and delirium tremens, and to ensure the client's safety. Restraints are not used as a precautionary measure. Restraints are used only as a least restrictive measure to protect the client and others when the client is a danger to himself or others.

"I'm a whale," a client with anorexia nervosa reports. However, the nurse's assessment reveals that the client is 5′ 8″ (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client's unrealistic body image, which intervention should be included in the care plan? confronting the client about actual appearance during one-on-one sessions, scheduled during each shift asking the client to make comparisons of self with people in magazines assigning the client to group therapy in which participants provide realistic feedback about the client's weight telling the client of the nurse's concern and desire to help the client make decisions to stay healthy

telling the client of the nurse's concern and desire to help the client make decisions to stay healthy A client with anorexia nervosa has an unrealistic body image that causes the client to consume little or no food. Therefore, this client needs assistance with making decisions about health. Instead of protecting the client's health, asking the client to make self comparisons with people in magazines, assigning the client to a group therapy, and confronting the client about actual appearance may make the client defensive and more invested in the unrealistic body image.

A nurse plans to include the parents of a client with anorexia nervosa in the client's therapy sessions. The nurse should anticipate that the parents will: tend to overprotect their child. have a history of substance abuse. maintain emotional distance from their child. alternate between expressing love for and rejection of their child.

tend to overprotect their child. A client with anorexia nervosa typically comes from a family in which parents are controlling and overprotective and emphasize perfection and achievement. These clients use eating to gain control over one aspect of their lives. Parents of children with anorexia nervosa tend not to have a history of substance abuse, maintain emotional distance, or alternate between expressing love and rejection.

Which outcome should the nurse use as the best measure to determine a client's progress in rehabilitation? the kinds of friends the client makes the way the client gets along with his or her parents the amount of responsibility the client's job entails the number of drug-free days the client has

the number of drug-free days the client has The best measure to determine a client's progress in rehabilitation is the number of drug-free days the client has. The longer the client abstains, the better the prognosis is. Although the kinds of friends the client makes, the way the client gets along with his or her parents, and the degree of responsibility the client's job requires could influence the client's decision to stay clean, the number of drug-free days is the best indicator of progress.

What information should the nurse plan to include when teaching the client and family about a substance abuse problem? the reasons that could have led the client to use the substance the physical, physiologic, and psychological effects of substances the role of the family in perpetuating the problem the family's responsibility for the client

the physical, physiologic, and psychological effects of substances The nurse should include teaching the client and family about the physical, physiologic, and psychological effects of substances to educate them about the potential injury, illness, and disability that can result from substance use. Teaching about the role of the family in perpetuating the problem, the family's responsibility for the client, or the reasons that could have led the client to use the substance is inappropriate and based on an erroneous assumption. Including these topics blames the family for the problem and attempts to rationalize the use of the substance.

While admitting a client to the alcohol treatment program, the nurse asks the client how long she has been drinking, how much she has been drinking, and when she had her last drink. The client replies that she has been drinking about a liter of vodka a day for the past week and her last drink was about an hour ago. This information helps the nurse to determine which factor? the occurrence of delirium tremens the possibility of alcoholic hallucinosis the severity of the disease the severity of withdrawal symptoms

the severity of withdrawal symptoms The client's response helps the nurse determine the severity of withdrawal symptoms because the length and extent of drinking alcohol has an effect on the severity of symptoms the client experiences during withdrawal. Decreased use of alcohol can also result in withdrawal symptoms in the client who has developed a high tolerance to alcohol and is physically dependent. The severity of the disease, the possibility of hallucinations, and the occurrence of delirium tremens are not determined by the information given. The diagnosis of alcohol dependency is just that—it is not classified as mild, moderate, or severe. Alcoholic hallucinosis is a state of auditory hallucinations that develops about 48 hours after the client has stopped drinking. The client hears voices or noises within the context of a clear sensorium, meaning that the auditory hallucination is the only symptom the client experiences. Severe withdrawal symptoms that are not managed medically can progress to delirium tremens or a severe abstinence syndrome. Delirium tremens occurs about 3 to 5 days after the client's last drink and is characterized by confusion, agitation, severe psychomotor activity, hallucinations, sleeplessness, tachycardia, elevated blood pressure, elevated temperature, and possibly seizures.

A client is hospitalized with fractures of the right femur and right humerus sustained in a motorcycle accident. Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dL; 43.2 mmol/dL). The client later admits to drinking heavily for years. The client periodically reports tingling and numbness in the hands and feet. Which finding does the nurse expect based on these symptoms? triglyceride level of 300 mg/dL (3.39 mmol/L) thiamine deficiency serum potassium level of 1.8 mEq/L (1.8 mmol/L) acetate accumulation

thiamine deficiency Numbness and tingling in the hands and feet are symptoms of peripheral polyneuritis, which results from inadequate intake of vitamin B1 (thiamine) secondary to prolonged and excessive alcohol intake. Treatment includes reducing alcohol intake, correcting nutritional deficiencies through diet and vitamin supplements, and preventing such residual disabilities as foot and wrist drop. Acetate accumulation is unrelated to the client's symptoms. The triglyceride level indicates buildup, but this is not related to the client's symptoms. The serum potassium level is below normal, but it is unrelated to the client's symptoms.

Before hospitalization, a client needed increasingly larger doses of barbiturates to achieve the same euphoric effect the client initially realized from their use. From this information, the nurse develops a plan of care that takes into account that the client is likely suffering from what problem? abuse addiction dependence tolerance

tolerance Tolerance for a drug occurs when a client requires increasingly larger doses to obtain the desired effect. Therefore, the plan of care would address the client's state of tolerance. The term addiction refers to psychological and physiologic symptoms indicating that an individual cannot control his or her use of psychoactive substances. This term has been replaced with the term dependence. Abuse refers to the excessive use of a substance that differs from societal norms. Drug dependence occurs when the client must take a usual or increasing amount of the drug to prevent the onset of abstinence symptoms, cannot keep drug intake under control, and continues to use even though physical, social, and emotional processes are compromised.

Which assessment provides the best information about the client's physiologic response and the effectiveness of the medication prescribed specifically for alcohol withdrawal? sleep pattern nutritional status vital signs evidence of tremors

vital signs Monitoring vital signs provides the best information about the client's overall physiologic status during alcohol withdrawal and the physiologic response to the medication used. Vital signs reflect the degree of central nervous system irritability and indicate the effectiveness of the medication in easing withdrawal symptoms. Although assessment of nutritional status and sleep pattern and assessment for evidence of tremors are important, they provide only indirect information about single aspects of the client's physiologic status.