Exam #4
A nurse decides to use the CAGE screening questionnaire with a client admitted for substance abuse. What is the client abusing? 1) Alcohol 2) Barbiturates 3) Hallucinogens 4) Multiple drugs
Answer: 1 Rationale: The CAGE questionnaire is one of the simplest and most reliable screening tools for alcohol abuse. CAGE is an acronym for the key words ( Cut down, Annoyed, Guilty, and Eye-opener) in the four questions asked of people suspected of abusing alcohol. The CAGE questionnaire is not designed to screen clients for barbiturate, hallucinogen, or multiple drug abuse.
According to Erikson's theory, what might the nurse suggest to the parent of a preschooler who has conflicts with the child due to strict behavior standards? 1) "Your behavior may induce a feeling of isolation in your child." 2) "You need to establish a sense of trust or the child may lose trust in you." 3) "Your child needs support and love or may develop feelings of shame and doubt." 4) "You need to cooperate with the child's desires within reason, or the child may suffer guilt and frustration."
Answer: 2 Rationale: According to Erikson, a child between 3 to 5 years of age is in the initiative versus guilt stage. The nurse might tell the parent to cooperate with the child's desires within reason in order to reduce conflicts. Otherwise, the child may have developed a sense of guilt and frustration. If a young adult is not able to develop companionship with others, then this can lead to a feeling of isolation. A feeling of mistrust can be seen in infants less than 1 year of age. Giving harsh punishments to a child may lead to a feeling of shame and doubt in the child and may hamper his or her healthy growth.
The nurse instructs the unlicensed assistive personnel (UAP) to obtain vital signs from four clients. From which client can the nurse instruct the UAP to obtain a radial pulse? 1) A 1-year-old child 2) An 18-month-old child 3) A 30-month-old child 4) A 6-month-old child
Answer: 3 Rationale: A satisfactory pulse can be taken radially in children older than 2 years of age, hence, the nurse can instruct the UAP to obtain a radial pulse from a 30-month-old child. It is not generally possible to take a satisfactory pulse radially in children younger than 18 months, therefore the nurse should not instruct the UAP to obtain a radial pulse from these children.
What is the best room assignment for a 5-year-old child admitted with injuries that may be related to abuse? 1) In an isolation room 2) With a friendly older child 3) With a child of the same age 4) In a room near the nurses' desk
Answer: 4 Rationale: A child who exhibits signs of abuse needs close supervision, especially when members of the family visit. The child requires close monitoring and should not be left alone. There is no indication that this child needs to be placed in an isolation room for the sake of infection control. An older child who exhibits signs of friendliness may be threatening to this child. Placement with a child of the same age may be desirable from a developmental level, but it does not meet the child's safety needs.
A nurse is teaching a group of parents about child abuse. What definition of assault should the nurse include in the teaching plan? 1) Assault is a threat to do bodily harm to another person. 2) Assault is a legal wrong committed by one person against the property of another 3) Assault is a legal wrong committed against the public that is punishable by federal law. 4) Assault is the application of force to another person without lawful justification.
Answer: 1 Rationale: Assault is a threat or an attempt to do violence to another. Assault implies harm to persons rather than property. A legal wrong committed against the public that is punishable by federal law is too broad to describe assault. Application of force to another person without lawful justification is the definition of battery.
What is the similarity between the stage-crisis theory given by Robert Havinghurst and the psychosocial development theory given by Erikson? 1) Both theories are based on developmental tasks. 2) Both theories incorporate eight stages of development. 3) Both theories are based on changes in a person's thoughts and emotions. 4) Both theories emphasize that a child's growth is directed by individual gene activity.
Answer: 1 Rationale: Both stage-crisis theory and psychosocial development theory are based on developmental tasks. Similar to Erikson's theory, Havinghurst's theory also demonstrates that the successful resolution of a developmental task is essential for successful progression through life. Stage-crisis theory has six stages; psychosocial development theory has eight stages of development. Gesell's theory of development shows that a child's development is directed by gene activity. Moral development theory emphasizes the changes in a person's thoughts, emotions, and behaviors that influence beliefs about what is right or wrong.
When planning for a client's care during the detoxification phase of acute alcohol withdrawal, what need should the nurse anticipate? 1) Checking on the client frequently 2) Keeping the client's room lights dim 3) Addressing the client in a loud, clear voice 4) Restraining the client during periods of agitation
Answer: 1 Rationale: During detoxification frequent checks help ensure safety and prevent suicide, which is a real threat. Bright light is preferable to dim light because it minimizes shadows that may contribute to misinterpretation of environmental stimuli (illusions). The client who is going through the detoxification phase of acute alcohol withdrawal usually does not lose his sense of hearing, so there is no need to shout. Restraints may upset the client further; they should be used only if the client is a danger to himself or others.
A nurse identifies that a client with dementia seems anxious, frequently paces about, and exhibits deteriorating hygiene. How can the nurse address these behaviors? 1) By directing staff members to reinforce reality with each client contact 2) By providing a restrictive environment, including restraints, to prevent self-injury 3) By ignoring instances when confabulation is used to substitute for memory lapses 4) By having the client identify positive coping skills to prevent feelings of inadequacy
Answer: 1 Rationale: Having staff members reinforce reality compensates for impaired cognition and helps provide a consistent approach, which may decrease the client's anxiety. Once anxiety is decreased, activities of daily living may be addressed. Restraints may increase confusion and agitation; they should be used only when absolutely necessary to prevent injury to self or others. Confabulation should be accepted, but it does not address the behaviors being exhibited. Having the client identify positive coping skills is not realistic; it will not help the client address activities of daily living.
A client reports drinking two drinks per day every day with no negative consequences. How should this person be classified? 1) Daily drinker 2) Substance abuser 3) Functional alcoholic 4) Substance dependent
Answer: 1 Rationale: If a client drinks two drinks per day every day with no negative consequences, the client is considered a daily drinker. If a client drinks over two drinks per day every day, the client has a potential for future problems. This person does not meet the criteria for any substance abuse or dependence diagnosis because there is no evidence of tolerance or other signs of substance dependence and no negative sequelae. There is no functional alcoholic diagnosis in the Diagnostic and Statistical Manual of Mental Disorders.
What important intervention should be included in the nursing care provided immediately after a sexual assault? 1) Obtaining the assault history from the client 2) Informing the police before the client is examined 3) Having the client void a clean-catch urine specimen 4) Testing the client's urine for seminal alkaline phosphatase
Answer: 1 Rationale: Obtaining the assault history from the client provides a basis for assessing trauma; in a client of childbearing age it also is necessary to assess the risk for pregnancy. Examination may precede reporting; the decision to report is mandated by law. Urination may wash away spermatic or bloody evidence. A test for seminal acid phosphate, not seminal alkaline phosphatase, is performed.
A salesman with a history of heavy drinking is on a detoxification unit. He asks the nurse's permission to skip the Alcoholics Anonymous (AA) meeting held each day. What is the nurse's initial response? 1) "What are your feelings about going to AA meetings?" 2) "What is it that you dislike about going to AA meetings?" 3) "It's all right to wait until you feel like going to AA meetings." 4) "An important part of your treatment is attending AA meetings."
Answer: 1 Rationale: Question 1 forces the client to face what going to AA meetings means to the client. Question 2 focuses the client on negative aspects; also, the client may be unable to answer this question. Response 3 reinforces avoidance, which delays dealing with the problem; the client may never feel like going to AA meetings. Although Response 4 is true, it does not explore the client's feelings.
A 65-year-old retired baker is admitted to the hospital with the diagnosis of dementia. What question by the nurse best tests the client's capacity for abstract thinking? 1) "How are a television and a radio alike?" 2) "Can you give me today's complete date?" 3) "What would you do if you fell and hurt yourself?" 4) "Repeat the following numbers for me: 8, 3, 7, 1, 5."
Answer: 1 Rationale: Question 1 forces the client to find a characteristic common to two things, an ability that is the criterion for abstract thinking. Question 2 tests orientation, not abstract thinking. Question 3 tests judgment, not abstract thinking. Question 4 tests short-term memory, not abstract thinking.
A client arrives at the clinic after being bitten by a raccoon in an area in the woods where rabies is endemic. When considering the client's needs, the nurse recalls that rabies is what? 1) Viral infection characterized by convulsions and difficulty swallowing 2) Parasitic infestation characterized by encephalopathy and opisthotonos 3) Bacterial septicemia resulting in convulsions and a morbid fear of water 4) Catalyst for an autoimmune response that results in a maculopapular rash and fever
Answer: 1 Rationale: Rabies is a viral infection characterized by convulsions, difficulty swallowing, and choking, which enters the body through a break in the skin. Rabies is not associated with a bacterial septicemia; a virus causes it. Rabies is not caused by parasites; its outstanding characteristics are convulsions and choking. The virus does not attack the autoimmune system; it specifically attacks nervous tissue.
A client with depression was prescribed fluoxetine. After two days, the client arrives at the hospital and reports restlessness, confusion, and poor concentration. Upon assessment, the nurse finds an elevated body temperature. Which intervention by the healthcare provider would be beneficial to the client? 1) Withdrawing the drug 2) Administering isocarboxazid 3) Reducing the dose of the drug 4) Informing the client that these are expected side effects
Answer: 1 Rationale: Restlessness, confusion, poor concentration, and fever are symptoms of serotonin syndrome. The only treatment for serotonin syndrome is discontinuation of the drug. Isocarboxazid is a monoamine oxidase inhibitor that should not be used in a client with serotonin syndrome because it may lead to life-threatening conditions. Reducing the drug dosage may not reverse the symptoms completely. Informing the client that these are expected adverse effects is important, but the drug should be discontinued immediately.
A client is admitted to the hospital with ascites. The client reports drinking a quart (liter) of vodka mixed in orange juice every day for the past three months. To assess the potential for withdrawal symptoms, which question would be appropriate for the nurse to ask the client? 1) "When was your last drink of vodka?" 2) "What prompts your drinking episodes? 3) "Do you also eat when you drink?" 4) "Why do you mix the vodka with orange juice?"
Answer: 1 Rationale: The nurse must determine when the client had the last drink to gauge when the body may react to lack of alcohol (withdrawal). Factors that prompt drinking are important but do not affect the body's response to withdrawal from the substance. Whether the client also eats when the client drinks will not influence the body's response to withdrawal from the alcohol. Whether the client mixes vodka with orange juice will not influence the body's withdrawal from the alcohol.
A nurse determines that the information about falling down the stairs given by a parent suspected of child abuse contradicts the information given by the child. What should the nurse say to the parent? 1) "Tell me again how your child fell down the stairs." 2) "Your child says the stairs did not cause this injury." 3) "Did you do anything to cause this injury to your child?" "Why don't you tell me what really happened to your child?
Answer: 1 Rationale: The nurse needs additional information to investigate the contradictory responses. The response "Your child says the stairs did not cause this injury" will put the parent on the defensive and may increase the child's risk for additional abuse. The response "Did you do anything to cause this injury to your child?" requires a yes or no response and will limit further discussion; it may also precipitate a defensive response. The response "Why don't you tell me what really happened to your child?" is judgmental, will interfere with further communication, and may precipitate a defensive response.
A client with alcoholism was admitted a few hours ago for pancreatitis. For which symptoms should the nurse carefully monitor this client? 1) Irritability and tremors 2) Yawning and convulsions 3) Disorientation and paranoia 4) Fever and profuse diaphoresis
Answer: 1 Rationale: The nurse should carefully monitor a client with alcoholism and pancreatitis for irritability and tremors when it has been a few hours since admission. Alcohol is a central nervous system depressant, and irritability and tremors are the body's neurologic adaptation during withdrawal of alcohol. Tachycardia, irritability, and tremors are the early signs of withdrawal and will appear 24 to 48 hours after the last alcoholic drink has been consumed. Convulsions (delirium tremens, or DTs), paranoia, and disorientation are later signs of severe alcohol withdrawal; fever and diaphoresis may occur with extended periods of delirium. Yawning occurs with heroin withdrawal.
While a client is attending an Alcoholics Anonymous (AA) meeting, a nurse talks with the client's spouse about the purpose of AA. What is the priority goal of this self-help group? 1) Changing destructive behavior 2) Developing functional relationships 3) Identifying how people present themselves to others 4) Understanding patterns of interacting within the group
Answer: 1 Rationale: The purpose of a self-help group is for individuals to develop their strengths and new, constructive patterns of coping. Developing functional relationships, identifying how people present themselves to others, and understanding patterns of interaction within the group are purposes of group therapy.
A client with a known history of opioid addiction is treated for multiple stab wounds to the abdomen. After surgical repair the nurse notes that the client's pain is not relieved by the prescribed morphine injections. The nurse realizes that the failure to achieve pain relief indicates that the client is probably experiencing what phenomenon? 1) Tolerance 2) Habituation 3) Physical addiction 4) Psychological dependence
Answer: 1 Rationale: Tolerance is a phenomenon that occurs in addicted individuals in which increasing amounts of the drug of addiction are needed to satisfy need; the client should receive adequate analgesia after surgery. Drug habituation is a mild form of psychological dependence; the individual develops a habit of taking the substance. A physical addiction is related to biochemical changes in body tissues, especially the nervous system. The tissues come to require the substance for usual function. Psychological dependence is emotional reliance on the substance to maintain a sense of well-being.
What factors may cause an adolescent to develop a smoking addiction? Select all that apply. 1) Peer pressure 2) Academic success 3) Involvement in sports 4) Imitating adult behavior of smoking 5) Imitating lifestyles portrayed in movies and advertisements
Answer: 1, 4, 5 Rationale: Factors that influence an adolescent to smoke include peer pressure and imitating adult behavior of smoking and lifestyles portrayed in movies. Succeeding in academics and being involved in sports are not factors that cause an adolescent to begin smoking.
How would the nurse explain preschoolers are different from school-aged children? Select all that apply. 1) Preschoolers have imaginary playmates. 2) Preschoolers are able to relate events to their causes. 3) Preschoolers are curious to know about their surroundings. 4) Preschoolers understand that one object can exist in two shapes. 5) Preschoolers believe that inanimate objects have lifelike qualities.
Answer: 1, 5 Rationale: Preschoolers have imaginary playmates, not school-aged children. Preschoolers believe that inanimate objects have feelings. They think that trees cry when their branches get broken. This thinking is not seen in school-aged children. Both preschoolers and school-aged children are able to relate events to their causes. Preschoolers and school-aged children are curious to know about their surroundings. Preschoolers are able to classify the objects based on size or color, whereas school-aged children understand that the same object can exist in two categories.
A toddler who was physically abused is admitted to the pediatric unit. What behavior does the nurse expect when approaching the child? 1) Smiling readily when anyone enters the room 2) Exhibiting fear of physical contact initiated by anyone 3) Beginning to cry when anyone approaches the bedside 4) Paying little attention to anyone standing at the bedside
Answer: 2 Rationale: Abused children distrust anyone who touches them because it may be a precursor to abuse. Abused children are fearful of others and do not smile when approached. Abused children usually do not cry because they have learned not to expect comforting behavior from others. An abused child is acutely aware of anyone at the bedside; he or she is alert to the possibility of an attack.
A hospitalized psychiatric client with the diagnosis of histrionic personality disorder demands a sleeping pill before going to bed. After being refused the sleeping pill, the client throws a book at the nurse. What does the nurse recognize this behavior to be? 1) Exploitive 2) Acting out 3) Manipulative 4) Reaction formation
Answer: 2 Rationale: Acting out is the process of expressing feelings behaviorally. The action is not exploitive, because no evidence is provided to demonstrate that anyone has been used to get what the client wants. The action is not manipulative, because no evidence is provided to demonstrate that anyone has been influenced against his or her wishes. The action is not disguising unacceptable feelings by expressing opposite emotions (reaction formation).
A client with a diagnosis of paranoid schizophrenia throws a chair across the room and starts screaming at the other clients. Several of these clients have frightened expressions, one starts to cry, and another begins to pace. A nurse removes the agitated client from the room. What should the nurse remaining in the room do next? 1) Continue the unit's activities as if nothing has happened. 2) Arrange a unit meeting to discuss what has just happened. 3) Refocus clients' negative comments to more positive topics. 4) Have a private talk with the clients who cried and started to pace.
Answer: 2 Rationale: Arranging a unit meeting to discuss what has just happened provides an opportunity for the other clients to voice and share feelings and to identify and separate real from imaginary fears; an open expression of feelings allows the nurse to address clients' fears and provide reassurance. Ignoring the situation denies reality and may precipitate or reinforce feelings of vulnerability and fear in the other clients. Refocusing clients' negative comments to more positive topics denies clients' concerns and could increase their anxiety and fear. Having a private talk with the clients who cried or started to pace may meet the needs of these two clients but ignores the needs of the other clients.
A client with the diagnosis of schizophrenia, paranoid type, appears very suspicious of the nurse. What is the most effective therapeutic nursing approach? 1) Assigning various caregivers to the client 2) Making brief, frequent contacts with the client 3) Initiating a discussion about the client's thoughts 4) Allowing the client to stay along without interruption
Answer: 2 Rationale: Brief, frequent contacts are less threatening and help build trust. Assigning various caregivers to the client will increase suspiciousness; the client needs consistent caregivers to help increase the level of trust. Initiating a discussion about the client's thoughts supports the client's delusions and thus increases suspiciousness. Allowing the client to stay alone without interruption does not engage the client in a therapeutic manner and reinforces the social withdrawal common with paranoia.
A nurse is counseling a client who abuses cocaine. The nurse recognizes that this drug is representative of which drug category? 1) An opioid 2) A stimulant 3) A barbiturate 4) A hallucinogen
Answer: 2 Rationale: Cocaine is classified as a stimulant. It is inhaled in its powdered form or smoked as crack; its use creates experiences similar to but more intense than those experienced with the amphetamines, and its withdrawal results in a deeper crash. Opioids and barbiturates are central nervous system depressants. Hallucinogens produce cerebral excitation that can yield a state similar to psychosis.
A client who is homeless is hospitalized for alcohol withdrawal. When considering the type of personal protective equipment that is needed for the client's care, what condition does the nurse recall that homeless persons are at risk for? 1) Prostatitis 2) Tuberculosis 3) Osteoarthritis 4) Diverticulosis
Answer: 2 Rationale: Medically underserved clients such as the homeless, clients who are alcohol or drug dependent, and those who have human immunodeficiency virus (HIV) infections are at risk for developing tuberculosis. Being homeless does not increase a person's risk for developing prostatitis, osteoarthritis, or diverticulosis.
What is the nurse's priority responsibility when abuse of an 8-year-old child is suspected? 1) Treating the child's traumatic injuries 2) Protecting the child from future abuse 3) Confirming the child's suspected abuse 4) Having the child examined by the healthcare provider
Answer: 2 Rationale: Most injuries to abused children are not life threatening; protection takes priority. Treatment of major injuries is the responsibility of the medical staff, not the nurse. An accurate diagnosis of child abuse may take time and must be fully investigated. The nurse is often the first person to see the abused child and must establish protection before the healthcare provider arrives.
A nurse is working with a married woman who has come to the emergency department several times with injuries that appear to be related to domestic violence. While talking with the nurse manager, the nurse expresses disgust that the woman keeps returning to the situation. What is the best response by the nurse manager? 1) "She must not have the financial resources to leave her husband." 2) "Most women try to leave about six times before they are successful." 3) "There's nothing the staff can do; people are free to choose their own lives." 4) "These women should be told how stupid they are to stay in that kind of situation."
Answer: 2 Rationale: Nurses who work with victims of partner abuse need to be supportive and patient. It takes time and several attempts for most victims to leave abusive relationships. It may or may not be true that the client does not have the financial resources to leave her husband; there is not enough information to support this conclusion. The staff can encourage the woman to make plans for addressing various potential events and provide information about social services and telephone help lines. Shaming women in this position will simply make them less likely to seek help.
A nurse is planning care for a client with substance-induced persisting dementia resulting from long-term alcohol use. Which nutritional problem, in addition to the effect of alcohol on brain tissue, has contributed to substance-induced persisting dementia? 1) Increase in serotonin 2) Deficiency of thiamine 3) Reduction in iron intake 4) Malabsorption of riboflavin
Answer: 2 Rationale: Substance-induced persistent dementia is caused by a prolonged deficiency of vitamin B1 (thiamine) and the direct toxic effect of alcohol on brain tissue. Increase in serotonin, reduction in iron intake, and malabsorption of riboflavin are problems that are unrelated to substance-induced persisting dementia caused by alcoholism.
A client is admitted to the mental health unit of the hospital because of agitation and unprovoked hostile verbal attacks toward others in the workplace. What is the priority nursing intervention for this client? 1) Developing trust 2) Maintaining safety 3) Refocusing hostile energy 4) Preventing hostile outbursts
Answer: 2 Rationale: The client is potentially harmful to others, as evidenced by previous episodes of hostile behavior. Developing trust is impossible until the client's anger and agitation begin to subside. Although refocusing hostile energy is important, it is not the priority. Preventing hostile outbursts may not always be possible.
A nurse administers oxygen at 2 L/min via nasal cannula to a client with emphysema. Which clinical indicators should the nurse closely observe in the client? Select all that apply. 1) Anxiety 2) Oxygenation 3) Drowsiness 4) Mental confusion 5) Increased respirations
Answer: 2, 3, 4 Rationale: A nurse administers oxygen at 2 L/min via nasal cannula to a client with emphysema. Which clinical indicators should the nurse closely observe in the client? Select all that apply.
A client with a disturbed state of mind is under observation. Which statement made by the nurse indicates that the client is suffering from dementia? Select all that apply. 1) "The client is very depressed." 2) "The client is not able to make a decision." 3) "The client always tells about his/her failures." 4) "The client is not able to perform purposeful work." 5) "The client has a completely disturbed sleep/wake cycle."
Answer: 2, 4 Rationale: A client with dementia may not able to make decisions because it affects thinking ability. The client with dementia may suffer from apraxia in which the client is not able to perform purposeful work. In depression, the client will remain depressed but in dementia, the mood is affected superficially. A client with depression may tell about his/her failures, but in dementia, the client may or may not be able to recollect details of life. In dementia, the sleep/wake cycle of the client is a bit fragmented but in depression, it is completely disturbed.
A 65-year-old man is admitted to a mental health facility with a diagnosis of substance-induced persisting dementia resulting from chronic alcoholism. When conducting the admitting interview, the nurse determines that the client is using confabulation. What does the nurse recall precipitates the client's use of confabulation? 1) Ideas of grandeur 2) Nee for attention 3) Marked memory loss 4) Difficulty in accepting the diagnosis
Answer: 3 Rationale: A client with this disorder has a loss of memory and adapts by filling in areas that cannot be remembered with made-up information. Ideas of grandeur do not occur with this type of dementia. The use of confabulation is not attention-seeking behavior; the individual is attempting to mask memory loss. This person is not coping with the diagnosis; when confabulating, the individual is attempting to mask memory loss.
The nurse is caring for an 84-year-old man admitted with a diagnosis of severe Alzheimer dementia. In the admission assessment, the nurse notes that the client can no longer recognize familiar objects such as his glasses and toothbrush. What is the best term to describe this situation? 1) Apraxia 2) Aphasia 3) Agnosia 4) Amnesia
Answer: 3 Rationale: Agnosia is the term used to describe the loss of sensory ability to recognize familiar sounds and objects, as well as loved ones or even parts of the affected individual's body. Amnesia is the term for the impairment of memory both recent and remote. Aphasia is the term for the loss of language ability, which progresses with the disease. Apraxia is the term for the loss of purposeful movement in the absence of motor or sensory impairment. The individual is unable to perform purposeful tasks such as walking or putting clothing on properly.
A healthcare provider prescribes losartan for a client. Which is the most important nursing action? 1) Assess the client for hypokalemia. 2) Ensure that the medication is ingested with food. 3) Monitor the client's blood pressure during therapy. 4) Teach that a missed dose can be doubled at the next scheduled time.
Answer: 3 Rationale: Losartan is an antihypertensive. It blocks vasoconstrictor and aldosterone-producing effects of angiotensin II at receptor sites. A lowering of the client's blood pressure reflects a therapeutic response and should be monitored frequently. The client may be at risk for hyperkalemia, not hypokalemia. Losartan may be taken without regard to meals. Doubling a dose is unsafe. A missed dose can be taken as long as it is not close to the next scheduled dose.
A mother is worried about the sudden behavioral changes in her child. The child has suddenly developed a fear of certain people and places. The child's school performance is declining rapidly, and the child has developed poor relationships with his or her peers. After assessing the physical findings of the child, the nurse suspects child abuse. Which physical findings might have led the nurse to this suspicion? 1) Sunken eyes and loss of weight 2) Uncommunicative and un-interactive with others 3) Foreign bodies in the rectum, urethra, or vagina 4) Strangulation marks on neck from rope burns or bruises
Answer: 3 Rationale: One of the physical findings that may be required to confirm child abuse is the presence of foreign bodies in the rectum, urethra, or vagina. Weight loss and sunken eyes may be a physical finding for older adult abuse. When the abuse is related to an intimate partner, the nurse may observe strangulation marks on the neck from rope burns or bruises. Staying isolated and not communicating with others are behavioral findings that may be related to older adult abuse.
A client comes to a trauma center reporting that she has been raped. She is disheveled, pale, and staring blankly. The nurse asks the client to describe what happened. What is the nurse's rationale for doing this? 1) It will help the nursing staff give legal advice and provide counseling. 2) Talking about the assault will help the client see how her behavior may have led to the event. 3) It will let the victim put the event in better perspective and help begin the resolution process. 4) Discussing the details will keep the victim from concealing the intimate happenings during the assault.
Answer: 3 Rationale: Talking about what actually happened helps the client sort out the truth from confused thoughts and helps the client begin to accept what has happened as a part of her history. Legal counsel should come from a legal authority, not the nurse; the victim should be told of the legal services available. Sexual assaults are often planned. They are violent acts, and the perpetrators are responsible for their behavior. If the client does not want to discuss intimate details, this wish should be respected.
A client with a history of heavy drinking is brought to a psychiatric facility in a stupor. On the day after admission the client is confused, disoriented, and delusional. What alcohol-related symptom does the nurse decide the client may be experiencing? 1) Amnesia 2) Hallucinations 3) Withdrawal syndrome 4) Uncomplicated dementia
Answer: 3 Rationale: The central nervous system is affected by the abrupt withdrawal of alcohol intake, resulting in the classic responses indicated in the situation; they occur 1 to 3 days after the cessation of alcohol intake. The information presented does not indicate the presence of impaired short- or long-term memory or of hallucinations. There are insufficient data with which to identify dementia; impairment of thought processes, judgment, and intellectual abilities must continue for 3 weeks or longer for dementia to be considered as a diagnosis.
A woman with five children comes to the emergency department with multiple facial injuries. The client says, "My husband is an alcoholic, and he just beat me up." The nurse concludes that the client appears to be a victim of abuse. What should the nurse do next? 1) Discuss birth control with her. 2) Report her experiences to the police. 3) Inquire about her and the children's safety. 4) Discuss the possibility of her and the children leaving her husband.
Answer: 3 Rationale: The safety of the victim and the children must be assessed, because research shows that children of an alcoholic parent are commonly abused. If the nurse suspects child abuse, a report must be made to child protective services. Birth control is a topic that may not be the client's concern; the client should be permitted to select the topic of conversation. Reporting the client's experiences to the police is not the legal responsibility of the nurse at this time. State laws determine whether the police must be contacted. The discussion of leaving the husband is premature. More information is needed.
Haloperidol 100 mg intramuscularly (IM) stat has been prescribed for a client who is battered and agitated after a street brawl. What does the nurse conclude after reviewing the prescription? 1) The medication is appropriate and should be given as prescribed. 2) The medication is inappropriate because it takes one week for antidepressants to be effective. 3) The dose is more than recommended. 4) The route of administration is incorrect.
Answer: 3 Rationale: The usual dose of IM haloperidol is 2 to 5 mg every two to four hours; the prescribed dose is above the maximum limit and should be questioned. Giving haloperidol 100 mg IM stat is unsafe. It is the nurse's responsibility to know the correct dose of a medication and to question a prescription that is more or less than the accepted limits. Haloperidol is an antipsychotic, not an antidepressant; antidepressants take two to three weeks to achieve a therapeutic effect. Haloperidol may be administered either orally or intramuscularly.
A client with a history of drug abuse begins group therapy. After attending the first meeting the client says to the nurse, "It helps to know that I'm not the only one with this type of problem." What concept does this statement reflect? 1) Altruism 2) Catharsis 3) Universality 4) Transference
Answer: 3 Rationale: Universality is the sense that one is not alone in any situation; one purpose of group therapy is to share feelings and gain support from others with similar thoughts and feelings. Altruism in group therapy is giving support, insight, and reassurance to others, which eventually promotes self-knowledge and growth. Catharsis involves group members relating to one another through the verbal expression of negative and positive feelings. Transference occurs when a client unconsciously assigns to the therapist feelings and attitudes originally associated with another important person in the client's life.
During the first month in a nursing home, a client demonstrates numerous disorganized behaviors related to disorientation and cognitive impairment. What should the nurse's plan of care continue to take into consideration in relation to the client? 1) Level of interest in unit activities 2) Orientation to time, place, and person 3) Ability to perform tasks without becoming frustrated 4) Cognitive impairment, which will increase until adjustment to the home is accomplished
Answer: 3 Rationale:When the client is unable to perform a task, frustration occurs and results in more disorganized behavior. Clients with disorientation and cognitive impairment may show little interest in unit activities but should be included to the best of their ability. However, this does not address the client's disorganized behaviors. The client's disorientation is documented and will not change, although some day-to-day variations may occur; most important is the assessment of the client's ability to function. The client will probably never adjust any further
What is the term used to identify the display of anger in a socially inappropriate manner? 1) Abuse 2) Battery 3) Aggression 4) Defensiveness
Answer: 3 Rationale:While experiencing and demonstrating anger is a normal human reaction, when that anger is displayed in behaviors that are socially and emotionally unacceptable, the behavior is termedaggressive. Defensiveness is a term that denotes the protection of oneself against real or perceived danger. Abuse is a general term that infers mistreatment of another individual that can be physical, sexual, emotional, or verbal. Battery is used to identify the carrying out of a verbal threat in a physical manner
A client with vascular dementia (formerly known as multiinfarct dementia) has signs and symptoms that are different from dementia of the Alzheimer type. What characteristics unique to vascular dementia should the nurse expect when assessing a client with this diagnosis? Select all that apply. 1) Memory impairment 2) Failure to identify objects 3) Exaggerated deep tendon reflexes 4) Episodic progression of symptoms 5) Inability to use words to communicate
Answer: 3, 4 Rationale: The diagnosis of vascular dementia is made when there is evidence of focal neurological signs and symptoms such as exaggerated deep tendon reflexes, extensor plantar response, gait abnormalities, and muscle weakness and when computed tomography reveals multiple infarcts involving the cortex and underlying white matter. Usually the signs and symptoms associated with vascular dementia have a steplike progression because of further intermittent occlusion of small arteries or arterioles in the cortex of the brain. Dementia of the Alzheimer type is associated with a gradual, progressive loss of memory and cognitive abilities. Both vascular dementia and dementia of the Alzheimer type are associated with deficits in memory and cognition. Failure to identify objects despite intact sensory function (agnosia) is a cognitive disturbance associated with both vascular dementia and dementia of the Alzheimer type. Both vascular dementia and dementia of the Alzheimer type are associated with language disturbances such as inability to use or understand words (aphasia).
A client who abused intravenous drugs was diagnosed with the human immunodeficiency virus (HIV) several years ago. What does the nurse explain to the client regarding the diagnostic criterion for acquired immunodeficiency syndrome (AIDS)? 1) Contracts HIV-specific antibodies 2) Develops an acute retroviral syndrome 3) Is capable of transmitting the virus to others 4) Has a CD4+ T-cell lymphocyte level of less than 200 cells/uL (60%)
Answer: 4 Rationale: AIDS is diagnosed when an individual with human immunodeficiency virus (HIV) develops one of the following: a CD4+T-cell lymphocyte level of less than 200 cells/µL (60%), wasting syndrome, dementia, one of the listed opportunistic cancers (e.g., Kaposi sarcoma [KS], Burkitt lymphoma), or one of the listed opportunistic infections (e.g., Pneumocystis jirovecipneumonia, Mycobacterium tuberculosis). The development of HIV-specific antibodies (seroconversion), accompanied by acute retroviral syndrome (flulike syndrome with fever, swollen lymph glands, headache, malaise, nausea, diarrhea, diffuse rash, joint and muscle pain) 1 to 3 weeks after exposure to HIV reflects acquisition of the virus, not the development of AIDS. A client who is HIV positive is capable of transmitting the virus with or without the diagnosis of AIDS.
When counseling the 20-year-old parents of a 13-month-old child, the nurse considers that the defense mechanism most often used by physically abusive parents is what? 1) Idealization 2) Manipulation 3) Transference 4) Displacement
Answer: 4 Rationale: Displacement is a defense mechanism in which one's pent-up feelings toward others who are a threat are discharged on others who are less threatening. Idealization is attributing overstated positive characteristics to others. Transference is a mechanism by which affects or emotional tones are shifted from one individual to another. Manipulation is a mechanism by which individuals attempt to manage, control, or use others to suit their own purpose or to gain an advantage.
A 45-year-old client who recently completed alcohol detoxification reports plans to begin using disulfiram (Antabuse) as part of the alcoholism treatment regimen. What important client teaching does the nurse share regarding this drug? 1) Voluntary compliance with the disulfiram regimen is very high. 2) A single dose of oral disulfiram will be effective for up to 72 hours. 3) Disulfiram may be taken intramuscularly and will be effective for as long as seven days. 4) Foods, medications, and any topical preparation containing alcohol should be avoided.
Answer: 4 Rationale: Disulfiram causes unpleasant physical effects when mixed with alcohol. Any substance that contains alcohol may trigger an adverse reaction. Voluntary compliance with the use of disulfiram is often very low because of the negative physical effects experienced by the individual if alcohol is ingested. For disulfiram to be effective, it must be taken orally every day. Disulfiram is not administered intramuscularly.
A primary healthcare provider prescribes oxazepam for a client who is beginning to experience withdrawal symptoms while undergoing detoxification. What are the primary reasons that oxazepam is given during detoxification? 1) Prevents injury and protects the client when seizures occur 2) Enables the client to sleep and eat better during periods of agitation 3) Encourages the client to cooperate with and accept treatment for alcoholism 4) Reduces the anxiety-tremor state and prevents more serious withdrawal symptoms
Answer: 4 Rationale: Oxazepam potentiates the actions of gamma-aminobutyric acid, especially in the limbic system and reticular formation and thus minimizes withdrawal symptoms. This drug helps reduce the risk for seizures but does not prevent injury or protect the client during a seizure. Enabling the client to sleep and eat better during periods of agitation is not the purpose of the drug. The ability of the client to accept treatment depends on the client's readiness to accept the reality of the problem.
A woman who is frequently physically abused tells the nurse in the emergency department that it is her fault that her husband beats her. What is the most therapeutic response by the nurse? 1) "Maybe it was your husband's fault, too." 2) "I can't agree with that—no one should be beaten." 3) "Tell me why you believe that you deserve to be beaten." 4) "You say that it was your fault—help me understand that."
Answer: 4 Rationale: Paraphrasing and clarifying are interviewing techniques that promote communication between the nurse and client and help the client hear and explore her words and gain insight into her behavior. "Maybe it was your husband's fault, too" is a declarative statement that is closed, will limit dialog, and is not therapeutic. When the nurse voices her opinion saying, "I can't agree with that—no one should be beaten", the nurse is shutting off communication with the client. Nurses are to be nonjudgmental and not offer an opinion, and should ask open-ended questions to facilitate communication with the client. Asking a "why" question is generally not therapeutic because most clients cannot respond to these questions with logical explanations.
A client with the diagnosis of alcoholism explains to the nurse that alcohol has a calming effect and states, "I function better when I'm drinking than when I'm sober." What defense mechanism does the nurse identify? 1) Sublimation 2) Suppression 3) Compensation 4) Rationalization
Answer: 4 Rationale: The attempt to justify a behavior by giving it acceptable motives is an example of rationalization. Sublimation is the substitution of a maladaptive behavior for a more socially acceptable behavior. Suppression is the intentional exclusion of things, people, feelings, or events from consciousness. Compensation is the attempt to emphasize a characteristic viewed as an asset to make up for a real or imagined deficiency.
An older client with depression is prescribed a tricyclic antidepressant. What is the priority nursing intervention in this situation? 1) Providing psychotherapy to the client 2) Teaching strategies to overcome depression 3) Encouraging the client to walk for 30 minutes 4) Requesting that the position change the drug
Answer: 4 Rationale: Tricyclic antidepressants have anticholinergic properties that can cause acute confusion, severe constipation, and urinary incontinence in older adults. Therefore, the priority nursing care for an older client who is prescribed a tricyclic antidepressant is to request that the physician change the drug. Providing psychotherapy is an alternate treatment, which is of medium priority. Teaching strategies to overcome depression is of low priority. Encouraging the client to walk for 30 minutes overcomes the feelings of depression, but it is not the priority.
A hospitalized client hurriedly approaches the nurse, saying that it sounds like there is a roaring fire in the bathroom. In reality, the client's roommate has just turned the shower on full force. What term best describes this experience? 1) Illusion 2) Delusion 3) Dissociation 4) Hallucination
Answer: 1 Rationale: An illusion is a misperception of an actual stimulus. A delusion is a fixed false belief that is unrelated to an external stimulus. Dissociation is a disturbance in the integrative functions of the client. A hallucination is a false perception with no actual external stimulus.
While assessing an older adult during a regular health checkup, a nurse finds signs of elder abuse. Which physical findings would further confirm the nurse's suspicion? Select all that apply. 1) Presence of hyoid bone damage 2) Presence of cognitive impairment 3) Presence of burns from cigarettes 4) Presence of bed sores 5) Presence of unexplained bruises on the wrists
Answer: 3, 4, 5 Rationale: A physical finding of abuse in older adults can be the presence of burns from cigarettes. The physical presence of bed sores also indicates client abuse. Unexplained bruises on the wrist(s) may also be an indication of abuse in older adults. The presence of hyoid bone damage is an indication of intimate partner violence. The presence of cognitive impairment is a behavioral finding in older adult abuse.
What should be a priority of nursing care for a client with dementia resulting from acquired immune deficiency syndrome (AIDS)? 1) Frequent assessments for pain 2) Planning of re-motivational therapy 3) Arranging for long-term custodial care 4) Providing basic intellectual stimulation
Answer: 4 Rationale: Providing basic intellectual stimulation maintains, for as long as possible, the client's remaining intellectual functions by providing an opportunity to use them. Although pain syndromes can occur in clients with dementia resulting from AIDS, frequent pain assessment is not a priority; providing cognitive stimulation facilitates the use of nonpharmacologic treatments for pain management as long as possible. Remotivation is not always possible with extensive organic brain damage. There are no data to indicate that the client needs custodial care at this time.
What behavior by a client with a long history of alcohol abuse is an indication that the client may be ready for treatment? 1) Drinking only socially 2) Not drinking for a week 3) Hospitalization for detoxification 4) Verbalizing an honest desire for help
Answer: 4 Rationale: When clients with alcohol problems voice a desire for help, it usually signifies that they are ready for treatment, because they are admitting they have a problem. Adherence to an alcohol treatment program requires abstinence. A week is too short a time to signal readiness for treatment. Hospitalization alone is not an indication that the client is really ready for treatment, because many factors can influence admission.
A nurse is providing information about Alcoholics Anonymous (AA) meetings to a client with a history of alcohol abuse. What will be required when the client attends AA meetings? 1) Speaking aloud at weekly meetings 2) Maintaining controlled drinking after 6 months 3) Promising to attend at least 12 meetings yearly 4) Acknowledging an inability to control the alcoholism
Answer:4 Rationale: A major premise of AA is that to be successful in achieving sobriety, clients with an alcohol abuse problem must acknowledge their inability to control the use of alcohol. There are no rules of attendance or speaking at meetings, although both actions are strongly encouraged. Maintaining controlled drinking after 6 months is not part of the AA program; this group strongly supports total abstinence for life.