Saunders- Ch.66: Addictions w/ Rationale
The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement? 1. "I no longer feel that I deserve the beatings my husband inflicts on me." 2. "My attendance at the meetings has helped me see that I provoke my husband's violence." 3. "I enjoy attending the meetings because they get me out of the house and away from my husband." 4. "I can tolerate my husband's destructive behaviors now that I know they are common among alcoholics."
Answer: 1 Rationale: Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavioral changes. The correct option is the healthiest response because it exemplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. Option 2 is incorrect, because the nonalcoholic partner should not feel responsible when the spouse loses control. Option 3 indicates that the group is viewed as an escape, not as a place to work on issues. Option 4 indicates that the wife remains codependent.
A hospitalized client with a history of alcohol misuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take? 1. Call the nursing supervisor. 2. Call security to block all exit areas. 3. Restrain the client until the primary health care provider (PHCP) can be reached. 4. Tell the client that the client cannot return to this hospital again if the client leaves now.
Answer: 1 Rationale: Most health care facilities have documents that the client is asked to sign relating to the client's responsibilities when the client leaves against medical advice. The client should be asked to wait to speak to the PHCP before leaving and to sign the "against medical advice" document before leaving. If the client refuses to do so, the nurse cannot hold the client against the client's will. Therefore, in this situation, the nurse should call the nursing supervisor. The nurse can be charged with false imprisonment if a client is made to believe wrongfully that she or he cannot leave the hospital. Restraining the client and calling security to block exits constitutes false imprisonment. All clients have a right to health care and cannot be told otherwise.
Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. 1. Monitor vital signs. 2. Provide a safe environment. 3. Address hallucinations therapeutically. 4. Provide stimulation in the environment. 5. Provide reality orientation as appropriate. 6. Maintain NPO (nothing by mouth) status.
Answer: 1, 2, 3, 5 Rationale: When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming self or others. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake need to be maintained.
The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? Select all that apply. 1. Dental decay 2. Moist, oily skin 3. Loss of tooth enamel 4. Electrolyte imbalances 5. Body weight well below ideal range
Answer: 1, 3, 4 Rationale: Clients with bulimia nervosa initially may not appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. On further inspection, a client exhibits dental decay and loss of tooth enamel if the client has been inducing vomiting. Electrolyte imbalances are present. Dry, scaly skin (rather than moist, oily skin) is present.
The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate? 1. Interrupt the client and weigh her immediately. 2. Interrupt the client and offer to take her for a walk. 3. Allow the client to complete her exercise program. 4. Tell the client that she is not allowed to exercise rigorously.
Answer: 2 Rationale: Clients with anorexia nervosa frequently are preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise and place limits on rigorous activities. The correct option stops the harmful behavior yet provides the client with an activity to decrease anxiety that is not harmful. Weighing the client immediately reinforces the client's preoccupation with weight. Allowing the client to complete the exercise program can be harmful to the client. Telling the client that she is not allowed to complete the exercise program will increase the client's anxiety.
A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior? 1. Normal behavior 2. Evidence of the client's disturbed body image 3. Regression as the client is moving toward the community 4. Indicative of the client's ambivalence about hospital discharge
Answer: 2 Rationale: Disturbed body image is a concern with clients with anorexia nervosa. Although the client may struggle with ambivalence and show regressed behavior, the client's coping pattern relates to the basic issue of disturbed body image. The nurse should address this need in the support group.
A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa? 1. A client with pneumonia 2. A client undergoing diagnostic tests 3. A client who thrives on managing others 4. A client who could benefit from the client's assistance at mealtime
Answer: 2 Rationale: The client undergoing diagnostic tests is an acceptable roommate. The client with anorexia nervosa is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client with anorexia nervosa at risk for infection. The client with anorexia nervosa should not be put in a situation in which the client can focus on the nutritional needs of others or be managed by others, because this may contribute to sublimation and suppression of personal hunger.
The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." Which is the most helpful response by the nurse? 1. "Why don't you tell your spouse about this?" 2. "What do you find difficult about this situation?" 3. "This is not the best time to make that decision." 4. "I agree with you. You should get out of this situation."
Answer: 2 Rationale: The most helpful response is one that encourages the client to solve problems. Giving advice implies that the nurse knows what is best and can foster dependency. The nurse should not agree with the client, and the nurse should not request that the client provide explanations.
The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? 1. Ask the client why he started taking illegal drugs. 2. Ask the client about the amount of drug use and its effect. 3. Ask the client how long he thought that he could take drugs without someone finding out. 4. Do not ask any questions for fear that the client is in denial and will throw the nurse out of the home.
Answer: 2 Rationale: Whenever the nurse carries out an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect because it is judgmental and off-focus, and reflects the nurse's bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention.
The nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? 1. Hypotension, ataxia, hunger 2. Stupor, lethargy, muscular rigidity 3. Hypotension, coarse hand tremors, lethargy 4. Hypertension, changes in level of consciousness, hallucinations
Answer: 4 Rationale: Symptoms associated with alcohol withdrawal delirium typically include anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of consciousness, agitation, fever, and delusions.
