Anxiety, Personality, & Substance-Rtd Disorders Lippy

151. 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. 1. Contact the security department. 2. Obtain an EKG. 3. Initiate a referral to obtain drug rehabilitation counseling. 4. Obtain a prescription for a urine sample.

151. ANS: 1, 2, 4, 3 1. Contact the security department. 2. Obtain an EKG. 4. Obtain a prescription for a urine sample. 3. 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 EKG because the client reports having chest pain. The nurse should then obtain a prescription for 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.

101. A 17-year-old female client who has been treated for an anxiety disorder since middle school with behavioral treatment and as-needed (PRN) anxiety medication is preparing to go to college. The parents are concerned that she will experience an exacerbation of symptoms if she attends college out of town and want the daughter to attend the local community college and live at home. The girl believes she can handle the challenge of leaving home for college. How should the nurse in the outpatient clinic respond to the family's concerns? 1. "Your parents have a point; transitions have been hard for you in the past." 2. "There are many pros and cons here that we all need to discuss together." 3. "Every high school graduate deserves the chance to take on new challenges." 4. "It may be premature for you to think of college at this point in time."

2. "There are many pros and cons here that we all need to discuss together." The nurse cannot appear to take the side of either the student or her mother, so discussing the situation together where all points of view can be presented and evaluated is the best optio

100. A client approaches the medication nurse and states, "I can't believe you are NOT helping me with my cravings for my fentanyl patches! When I got off alcohol 2 years ago, they gave me naltrexone for my cravings, and it really helped. I can't stand the cravings and back pain anymore, and I'm getting angry." Which of the following responses by the nurse would be helpful for this client? Select all that apply. 1. "Naltrexone does help decrease the cravings for alcohol." 2. "Naltrexone can interfere with opiate cravings in some clients." 3. "Cravings are hard to deal with, especially when you are in pain too." 4. "I hear your frustration about how your detoxification is going." 5. "I am positive naltrexone can help with your cravings for fentanyl." 6. "I can ask your physician if he thinks naltrexone might help you."

ANS: 1, 2, 3, 4, 6. 1. "Naltrexone does help decrease the cravings for alcohol." 2. "Naltrexone can interfere with opiate cravings in some clients." 3. "Cravings are hard to deal with, especially when you are in pain too." 4. "I hear your frustration about how your detoxification is going." 6. "I can ask your physician if he thinks naltrexone might help you." Acknowledgment of the client's frustration, pain, and cravings is important to decrease the client's anger. Naltrexone can help with detoxification from alcohol and opiates. Asking the physician about the possibility of adding naltrexone is appropriate. The nurse can never promise that a medication will help this client, since naltrexone is effective with only 20% to 30% of clients with opiate cravings.

87. A client is being admitted to the addictions unit for a confirmed and long-term addiction to Xanax (alprazolam). She continues to strongly deny her addiction, stating she was prescribed the Xanax to control her "panic attacks." Which of the following procedures would be the most important during the admission process? Select all that apply. 1. Assess the client for suicide, escape, and aggression risks. 2. With the client present, search the client's clothes and belongings for contraband and restricted items. 3. Initiate withdrawal precautions. 4. Explain the unit routine and types of groups. 5. Obtain a urine specimen for a urine drug screen.

ANS: 1, 2, 3, 5. 1. Assess the client for suicide, escape, and aggression risks. 2. With the client present, search the client's clothes and belongings for contraband and restricted items. 3. Initiate withdrawal precautions. 5. Obtain a urine specimen for a urine drug screen. Clients who deny an addiction and the need for treatment can be at risk for a suicide attempt, efforts to escape the unit, and aggression directed at staff. A contraband search is a safety measure to look for concealed drugs and dangerous items. Depending on the last use of the substance, withdrawal symptoms can begin quickly. A urine drug screen is crucial to determine what other substances the client may be using that may cause other withdrawal symptoms. Explaining the unit routines and groups can wait until the client is calmer and more receptive.

103. A client has been diagnosed with posttraumatic stress disorder (PTSD) because he experienced childhood sexual abuse (CSA) by his babysitter and her boyfriend from ages 4 to 10. He is admitted for the second time after physically assaulting a woman he said was a prostitute. "She is no better than my babysitter and deserves to be dead. I'd like to kill the sitter too." With the knowledge of PTSD and CSA, which of the following nursing interventions should be implemented at admission? Select all that apply. 1. Institute precautions for suicide, assault, and escape. 2. Ask him to sign a no harm contract. 3. Provide safe outlets for his anger and rage. 4. Encourage him to express his attitude toward prostitutes during unit group sessions. 5. In one-to-one staff talks, encourage him to safely verbalize his anger toward his babysitter and her boyfriend.

ANS: 1, 2, 3, 5. 1. Institute precautions for suicide, assault, and escape. 2. Ask him to sign a no harm contract. 3. Provide safe outlets for his anger and rage. 4. Encourage him to express his attitude toward prostitutes during unit group sessions. 5. In one-to-one staff talks, encourage him to safely verbalize his anger toward his babysitter and her boyfriend. Anger and rage could be directed at self and others. He implies that he did nothing wrong in assaulting the woman (denial) and may try to leave without treatment. A No Harm Contract is essential for everyone's safety. He needs safe outlets, including staff talks, for his anger. Talking about his views of prostitutes in unit groups may be upsetting to female clients who have sexual abuse issues as well, so this needs to occur in private.

9. A client diagnosed with paranoid personality disorder is being admitted on an Immediate Detention Order (24-hour hold) after a physical altercation with a police officer who was investigating the client's threatening phone calls to his neighbors. He states that his neighbors are spying on him for the government. "I want them to stop and leave me alone. Now they have you nurses and doctors involved in their conspiracy." Which of the following nursing approaches are most appropriate? Select all that apply. 1. Approach the client in a professional, matter-of-fact manner. 2. Avoid intrusiveness in interactions with the client. 3. Gently present reality to counteract the client's current paranoid beliefs. 4. Develop trust consistently with the client. 5. Do not pressure the client to attend any groups.

ANS: 1, 2, 4, 5. 1. Approach the client in a professional, matter-of-fact manner. 2. Avoid intrusiveness in interactions with the client. 4. Develop trust consistently with the client. 5. Do not pressure the client to attend any groups. A professional, matter-of-fact approach and developing trust are the most effective with this client. A friendly approach, intrusiveness, and attempting to counteract the client's beliefs will increase the client's paranoia; he will present more false beliefs to prove he is right about the conspiracy. In groups, questions from peers, confrontations with reality, and the emotionality will increase the client's anxiety.

33. The nurse is assessing a client who has fallen twice in the last 2 days. The client has been diagnosed with delirium tremens (DTs) following withdrawal from alcohol use. The nurse should further evaluate the client for which of the following? Select all that apply. 1. Disorientation. 2. Paralysis. 3. Elevated temperature. 4. Diaphoresis. 5. Visual or auditory hallucinations.

ANS: 1, 3, 4, 5. 1. Disorientation. 3. Elevated temperature. 4. Diaphoresis. 5. Visual or auditory hallucinations. Two or three days after cessation of alcohol, clients may experience delirium tremens (DTs), as evidenced by disorientation, nightmares, abdominal pain, nausea, and diaphoresis, as well as elevated temperature, pulse, and blood pressure, and visual and auditory hallucinations. If the client had a traumatic brain injury after falling, the client might have paralysis, but there is no association of paralysis from DTs.

99. In consultation with his outpatient psychiatrist, a client is admitted for detoxification from methadone. He states, "I got addicted to morphine for my chronic knee pain. Methadone worked for a long time. Since I had my knee replacement surgery 3 months ago and physical therapy, I don't think I need methadone any more." It is important to discuss which of the following pieces of information with this client? Select all that apply. 1. "Detoxification will likely occur with slowly decreasing doses of methadone." 2. "Oxycodone will be available if needed for break-through-pain." 3. "You will be monitored closely for withdrawal symptoms and treated as needed." 4. "Physical therapy and nonchemical pain management techniques can be prescribed if needed." 5. "If you have knee stiffness or pain, it is likely to be managed by nonnarcotic pain medicines."

ANS: 1, 3, 4, 5. 1. "Detoxification will likely occur with slowly decreasing doses of methadone." 3. "You will be monitored closely for withdrawal symptoms and treated as needed." 4. "Physical therapy and nonchemical pain management techniques can be prescribed if needed." 5. "If you have knee stiffness or pain, it is likely to be managed by nonnarcotic pain medicines." Since methadone is an addictive medication, the client will be gradually tapered off of it, while monitoring him for withdrawal symptoms. Any residual pain is likely to be controlled with other pain management techniques and nonnarcotic pain medication. It is very unlikely that oxycodone would be prescribed PRN since it is a very addictive medication.

8. A new client on the psychiatric unit has been diagnosed with depression and obsessive-compulsive personality disorder (OCPD). During visiting hours, her husband states to the nurse that he doesn't understand this OCPD and what can be done about it. What information should the nurse share with the client and her husband? Select all that apply. 1. Perfectionism and overemphasis on tasks usually interfere with friendships and leisure time. 2. It will help to interrupt her tasks and tell her you are going out for the evening. 3. There are medicines, such as clomipramine (Anafranil) or fluoxetine (Prozac) that may help. 4. Remind your wife that it is "OK" to be human and make mistakes. 5. Reinforce with her that she is not allowed to expect the whole family to be perfect too. 6. This disorder typically involves inflexibility and a need to be in control.

ANS: 1, 3, 4, 6. 1. Perfectionism and overemphasis on tasks usually interfere with friendships and leisure time. 3. There are medicines, such as clomipramine (Anafranil) or fluoxetine (Prozac) that may help. 4. Remind your wife that it is "OK" to be human and make mistakes. 6. This disorder typically involves inflexibility and a need to be in control. Inflexibility, need to be in control, perfectionism, overemphasis on work or tasks, and a fear of making mistakes are common symptoms of OCPD. Anafranil and Prozac may help with the obsessive symptoms, Interrupting the client's tasks is likely to increase her anxiety even more. Telling her that she cannot expect the family to be perfect is likely to create a power struggle.

38. The client is feeling better as the symptoms of alcohol withdrawal abate. She refuses information about alcohol rehabilitation and states, "I don't have a problem. I'll never drink like that again. I learned my lesson this time. I guess I'll just have to switch to beer or wine." The nurse should respond by: 1. Discussing how alcohol has gotten her into trouble. 2. Explaining the effects of drinking on her family. 3. Urging her to attend Alcoholics Anonymous meetings. 4. Telling her about the physiologic damage that can result.

ANS: 1. Discussing how alcohol has gotten her into trouble. The most effective way to help decrease the client's denial is to point out how alcohol has gotten the client into trouble, using specific, concrete data based on fact, not opinion. Explaining the effects of drinking on family, urging the client to attend Alcoholics Anonymous meetings, and telling her about the physiologic damage that can result are important components of the treatment process but are not as effective in decreasing denial as discussing how alcohol has affected her life.

80. A client who has experienced the loss of her husband through divorce, the loss of her job and apartment, and the development of drug dependency is suffering situational low self-esteem. Which of the following outcomes is most appropriate initially? 1. The client will discuss her feelings related to her losses. 2. The client will identify two positive qualities. 3. The client will explore her strengths. 4. The client will prioritize problems.

ANS: 1. The client will discuss her feelings related to her losses. The most appropriate initial outcome for the client is to discuss thoughts and feelings related to her losses. The nurse should help the client identify and verbalize her feelings so that she can externalize her thoughts and emotions and begin to deal with them. This prevents the client from internalizing feelings, which leads to depression and self-harm. The ability to identify two positive qualities, explore strengths, and prioritize problems would be appropriate after the client has explored her thoughts and feelings, gained awareness of the issues, and then can participate in the treatment plan.

82. The nurse identifies a nursing diagnosis of Situational low self-esteem for a client who has experienced the loss of her husband through divorce, the loss of her job and apartment, and the development of drug dependency. Which of the following outcomes is most appropriate initially? 1. The client will discuss her feelings related to her losses. 2. The client will identify two positive qualities. 3. The client will explore her strengths. 4. The client will prioritize problems.

ANS: 1. The client will discuss her feelings related to her losses. The most appropriate initial outcome for the client is to discuss thoughts and feelings related to her losses. The nurse should help the client identify and verbalize her feelings so that she can externalize her thoughts and emotions and begin to deal with them. This prevents the client from internalizing feelings, which leads to depression and self-harm. The ability to identify two positive qualities, explore strengths, and prioritize problems would be appropriate after the client has explored her thoughts and feelings, gained awareness of the issues, and then can participate in the treatment plan.

98. The nurse is to administer Xanax (alprazolam) to help a client of Japanese descent calm down. The order reads Xanax 0.25 to 1 mg by mouth as needed for agitation. What is the best dose for the nurse to give this client? ________________________ mg.

ANS: 2 mg. Asians have a greater sensitivity to psychotropic medication and generally require much less than other cultural groups to achieve positive results. The smallest dose is safest to start; the dosage can always be increased. However, a dose that is too high for the client is likely to cause unpleasant or even serious side effects. Those side effects likely would lead to distress and noncompliance in the future.

27. In an outpatient addictions 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 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 use to ignore that stuff. I don't know what to do." The nurse would make the following comments in which order of priority from first to last? 1. "What do you think you could do to have your husband come in for an evaluation?" 2. "I hear how confused and frustrated you are." 3. "It can happen that as one person sobers up, the spouse deteriorates." 4. "What have you tried to do about your husband's behaviors?"

ANS: 2, 3, 4, 1 2. "I hear how confused and frustrated you are." 3. "It can happen that as one person sobers up, the spouse deteriorates." 4. "What have you tried to do about your husband's behaviors?" 1. "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 that 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.

88. A client is returning to the primary care physician's office for follow-up on his diagnosis of coronary artery disease. After all the appropriate exams and assessments are completed, the nurse asks the client about how well he is sleeping. The client states, "Oh, that's not a problem anymore. I take a couple of my wife's Valiums (diazepam) and sleep like a baby." Which of the following information should the nurse obtain? Select all that apply. 1. The reason the client's wife is taking Valium. 2. The dose of the Valium he is taking and how long he has been taking it. 3. Exactly how many Valiums he takes at night and during the day, 4. Whether he intends to stop the Valium use. 5. What was interfering with his sleep prior to starting the Valium.

ANS: 2, 3, 5. 2. The dose of the Valium he is taking and how long he has been taking it. 3. Exactly how many Valiums he takes at night and during the day, 5. What was interfering with his sleep prior to starting the Valium. The dose, length of use, and the number of Valiums taken per day are important for assessing the severity of the substance abuse and potential withdrawal. Determining sleep interferences is necessary for treating the underlying causes of the insomnia. The reason his wife takes Valium is confidential information and not critical to his situation. Getting off the Valium is essential, not an option, especially with his cardiac issues. This needs to be done safely if he has been taking it for more than a week or 2.

87. A client in the emergency department tells the nurse that he "sees sounds and hears colors" as a result of using lysergic acid diethylamide (LSD). He also has elevated vital signs and mild paranoia. The nurse should do which of the following? Select all that apply. 1. Induce vomiting. 2. Decrease stimuli. 3. Apply restraints for safety. 4. Monitor vital signs every 30 minutes. 5. Talk reassuringly to help with relaxation. 6. Administer lorazepam (Ativan) if anxiety increases.

ANS: 2, 4, 5, 6. 2. Decrease stimuli. 4. Monitor vital signs every 30 minutes. 5. Talk reassuringly to help with relaxation. 6. Administer lorazepam (Ativan) if anxiety increases The client is experiencing "synesthesia", the blending of senses. At this point, the client needs decreased stimuli and reassurance that the "trip" effects will decrease. Monitoring the vital signs also provides frequent contact with the client to see if Ativan will be needed to decrease anxiety. Inducing vomiting is not needed, nor are there any behaviors that warrant restraints.

11. The client diagnosed with major depression and dependent personality disorder has made the decision to live independently in an apartment. The nurse and the client meet with his parents to discuss his decision. Which statement by the nurse is most helpful to foster the client's independence? 1. "You'll still be able to see your son and help him as much as you want." 2. "All of you will gain from his independent living; he needs our support." 3. "You'll need to help monitor his medication and clinic appointments." 4. "You'll live nearby and be able to help with meals and laundry."

ANS: 2. "All of you will gain from his independent living; he needs our support." Stating, "All of you will gain from his independent living; he needs our support," encourages the client's independent behaviors and fosters autonomous functioning for the entire family. The other statements minimize the son's independence and decrease his self-esteem.

53. Which of the following client statements indicates an understanding of the signs of alcohol relapse? 1. "I know I can stay dry if my wife keeps alcohol out of the house." 2. "Stopping Alcoholics Anonymous (AA) and not expressing feelings can lead to relapse." 3. "I'll have my sponsor at AA keep the list of symptoms for me." 4. "If someone tells me I'm about to relapse, I'll be sure to do something about it."

ANS: 2. "Stopping Alcoholics Anonymous (AA) and not expressing feelings can lead to relapse." The statement, "Stopping Alcoholics Anonymous and not expressing feelings can lead to relapse," indicates the client's understanding of signs of relapse. The client is responsible for sobriety and must understand the signs of relapse. Other antecedents to relapse include severe craving, being around users, and severe emotional crises. The other statements place the responsibility for the client's sobriety on someone else.

9. Which of the following approaches should the nurse expect to include in the plan of care for a client diagnosed with antisocial personality disorder who has a history of stealing and jail time? 1. Helping the client develop a conscience. 2. Teaching the client consequences of her actions. 3. Assisting the client with understanding right from wrong. 4. Using strategies to help the client become passive.

ANS: 2. Teaching the client consequences of her actions. The nurse should teach the client consequences of her actions to help the client understand that if she steals she will get into legal trouble and be put in jail. So, if she wants to avoid jail, she needs to not steal. Helping the client to develop a conscience or to understand right from wrong is impossible. However, the client needs to be taught that her actions do lead to consequences. Using strategies to help the client become passive is not helpful, is nontherapeutic, and does not help the client to understand the consequences of her actions.

117. A 15-year-old client diagnosed with PTSD is admitted to the unit after slicing both arms with a razor blade. He says, "Maybe my mother will listen to me now. She tells me I'm just crazy when I say I'm screwed up because my step dad had sex with me for years." The nurse should do the following in which order of priority fi rst to last? 1. Ask the client about the step dad possibly abusing younger children in the family 2. Ask the client to be specifi c about what he means by "screwed up." 3. Ask the client to sign a No Harm Contract related to suicide and self-mutilation. 4. Ask the client to talk about appropriate ways to express anger toward his mother.

ANS: 3, 1, 2, 4 3. Ask the client to sign a No Harm Contract related to suicide and self-mutilation. 1. Ask the client about the step dad possibly abusing younger children in the family 2. Ask the client to be specific about what he means by "screwed up." 4. Ask the client to talk about appropriate ways to express anger toward his mother. The nurse should first assure the client's safety after the client's self-mutilation. Another safety issue is whether the step dad possibly may be abusing younger children; if so, a police report may need to be fi led. Then, it is important to know what the client means exactly by "screwed up" to identify other emotions and behaviors that need attention. It is very common for survivors of childhood sexual abuse to have intense anger at those who did not stop or prevent the abuse, and once the other steps have been taken, the nurse can begin to help the client manage his anger.

150. Two nurses are working on a pediatric unit. Over the past week, Nurse 1 has noticed that Nurse 2 is complaining more about her chronic back pain. Nurse 2 also says she is tired and drowsy at work. She is having trouble remembering which treatments she has done. Around the same time, a client of Nurse 2 reports that his pain medication is not helping at all. Nurse 1 asks Nurse 2 to have lunch with her to address her concerns about her. In which order of priority from first to last should Nurse 1 address the following issues with Nurse 2? 1. The type, dose, and frequency of use of the pain medication by Nurse 2. 2. The importance of the two of them going to their supervisor about Nurse 2's recent problems. 3. Nurse 1's genuine concern about Nurse 2, her pain, and behaviors. 4. Nurse 1's suspicion that Nurse 2 may be using a client's pain medication for herself.

ANS: 3, 1, 4, 2 3. Nurse 1's genuine concern about Nurse 2, her pain, and behaviors. 1. The type, dose, and frequency of use of the pain medication by Nurse 2. 4. Nurse 1's suspicion that Nurse 2 may be using a client's pain medication for herself. 2. The importance of the two of them going to their supervisor about Nurse 2's recent problems. Unless Nurse 2 believes that Nurse 1 cares about her and her needs, she is likely to deny having any problem. Knowing details about Nurse 2's pain medications, helps Nurse 1 assess the severity of Nurse 2's medication abuse. Then it is appropriate to address the possibility of Nurse 2 using a client's pain medication. Going to their supervisor is the next step in helping Nurse 2 get treatment assistance.

85. A young client is being admitted to the psychiatric unit after her obstetrician's staff suspected she was experiencing a postpartum psychosis. Her husband said she was doing fine for 2 weeks after the birth of the baby, except for pain from the C-section and trouble sleeping. These symptoms subsided over the next 4 weeks. Then 3 days ago, the client started having anxiety, irritability, vomiting, diarrhea, and delirium, resulting in her inability to care for the baby. Then the husband says, "I saw that my bottles of alprazolam and oxycodone were empty even though I haven't been taking them." In what order of priority from first to last should the nurse do the following? 1. Call the physician for prescriptions for appropriate treatment for opiate and benzodiazepine withdrawal. 2. Immediately place the client on withdrawal precautions. 3. Confirm with the client that she has in fact been using her husband's medications. 4. Assess the client for prior and current use of any other substances.

ANS: 3, 4, 2, 1 3. Confirm with the client that she has in fact been using her husband's medications. 4. Assess the client for prior and current use of any other substances. 2. Immediately place the client on withdrawal precautions. 1. Call the physician for prescriptions for appropriate treatment for opiate and benzodiazepine withdrawal. It crucial to confirm that the client was taking her husband's opiates and benzodiazepines and that her symptoms are due to the sudden withdrawal from these medications. It is also important to know if she has been using other substances (such as alcohol) that may cause other withdrawal symptoms. Even before calling the physician for prescriptions, the nurse can initiate withdrawal precautions for client safety.

55. 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? 1. "Your doctor wants you to take it for at least 4 months." 2. "You've been drinking alcohol and eating very little." 3. "The vitamin is a nutritional supplement important to your health." 4. "The amount of vitamins in the alcohol you drink is very low."

ANS: 3. "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.

25. The client with an Axis II diagnosis of narcissistic personality disorder tells the nurse he can get an executive position with the best company around anytime he wants. The history reveals that the client, whose highest level of education completed is high school, has held only a series of short-term part-time jobs for the past 2 years. The nurse interprets the client's statement to be an example of which of the following? 1. Grandiose delusion. 2. Blatant lie. 3. Grandiose self-importance. 4. Sense of entitlement.

ANS: 3. Grandiose self-importance. The nurse judges the client's statement to be an example of grandiose self-importance, which is not a lie but an overvaluing of oneself. The grandiosity of a client with a narcissistic personality disorder is not a delusion because it usually is based somewhat in reality. However, it can be distorted, embellished, or convoluted to meet the client's need of self-importance. Sense of entitlement is a symptom of the narcissistic client but refers to deserving to be favored or given special treatment.

34. A client was discharged from an alcohol rehabilitation program on clonazepam (Klonopin) 0.5 mg TID. Several months later he reports having insomnia, shakiness, sweating and one seizure. The nurse should fi rst ask the client if he: 1. Has been drinking alcohol with the Klonopin. 2. Has developed tolerance to the Klonopin and needs to increase the dose. 3. Has stopped taking the Klonopin suddenly. 4. Is having a panic attack and needs to take an extra Klonopin.

ANS: 3. Has stopped taking the Klonopin suddenly. The nurse should first confirm that the client has stopped taking the Klonopin because the client is reporting symptoms of benzodiazepine withdrawal from stopping the Klonopin abruptly. The client would report symptoms of being sedated if he took alcohol with the Klonopin. Tolerance symptoms would be increased anxiety, not these physical symptoms. Klonopin is an appropriate medication for panic attacks, but taking extra pills without physician approval is not appropriate.

34. A client was discharged from an alcohol rehabilitation program on clonazepam 0.5 mg three times a day. Several months later he reports having insomnia, shakiness, sweating, and one seizure. The nurse should first ask the client if he: 1. Has been drinking alcohol with the clonazepam. 2. Has developed tolerance to the clonazepam and needs to increase the dose. 3. Has stopped taking the clonazepam suddenly. 4. Is having a panic attack and needs to take an extra clonazepam.

ANS: 3. Has stopped taking the clonazepam suddenly. The nurse should first confirm that the client has stopped taking the clonazepam because the client is reporting symptoms of benzodiazepine withdrawal from stopping the clonazepam abruptly. The client would report symptoms of being sedated if he took alcohol with the clonazepam. Tolerance symptoms would be increased anxiety, not these physical symptoms. Clonazepam is an appropriate medication for panic attacks, but taking extra pills without primary health care provider approval is not appropriate.

26. A client has been diagnosed with dementia related to chronic and heavy alcohol consumption. In a family meeting with the client, discharge plans are being discussed. Which of the following points should the nurse share with the family and client? Select all that apply. 1. The house and garage need to be searched and all the alcohol products destroyed. 2. Without continued alcohol intake, the client will gradually get better. 3. With the memory loss, answer the client's question once, and then ignore that question when asked again. 4. Safety alarms on the doors will help to keep the client from wandering off. 5. As the need for supervision increases, it may be necessary for the client to be placed in an extended care facility.

ANS: 4, 5. 4. Safety alarms on the doors will help to keep the client from wandering off. 5. As the need for supervision increases, it may be necessary for the client to be placed in an extended care facility. As with any dementia, there is a need to protect the client from wandering off and risking harm to self. Dementia is progressive and eventually requires 24-hour supervision. Destroying the alcohol is notably ineffective; the client will find a way to get more if quitting is not a personal goal. Not answering the client's question will generally increase the client's anger. Once the dementia is evident, lack of alcohol intake will not reverse the condition.

8. A client was admitted after making a suicidal gesture in a police car. He is diagnosed with Antisocial Personality Disorder and has been stealing equipment from his work. He states, "It's not a big deal. My boss can afford a few missing pieces. He picks on me anyway." Which of the following is the most appropriate response by the nurse? 1. "Have the police charged you with the thefts?" 2. "Stealing is a crime regardless of the reason." 3. "I bet your boss doesn't think he can afford the losses." 4. "Are you having any guilt feelings at all?"

ANS: 4. "Are you having any guilt feelings at all?" The client diagnosed with an antisocial personality disorder is manifesting behavior indicative of problems in Erikson's stage of initiative versus guilt. Typical behaviors of a client with an antisocial personality disorder are engaging in illegal activities, violating the rights of others, lack of guilt or remorse, recklessness, impulsiveness, aggressive behavior, and irresponsibility in work and with finances, and the nurse should determine if the client is feeling any guilt. A lack of guilt or remorse for offenses, such as stealing, is typically present, as if the client does not have a conscience. Behaviors indicating problems in the stage of trust versus mistrust include suspiciousness, projection of blame and feelings, and withdrawal. Behaviors indicating problems in the stage of autonomy versus shame and doubt include self-doubt and self-consciousness, dependency on others for approval, and denial of problems. Behaviors indicating problems in the stage of industry versus inferiority include poor work history, inadequate problem-solving skills, and manipulation of others.

86. A 68-year-old client is admitted to the addiction unit after treatment in the Emergency Department for an overdose of Percocet (oxycontin). Her son calls the unit and expresses intense anger that his mother is being treated as a "common street addict." He says she has severe back pain and was given that prescription by her doctor. "She just accidentally took a few too many pills last night." Which reply by the nurse is most therapeutic? 1. "I understand that your mother may not have intentionally taken too many pills. This medication can cause one to forget how many have been taken." 2. "It may be appropriate for your mother to be referred to a pain management program." 3. "Unfortunately, it is fairly common for clients with pain to increase their use of pain pills over time." 4. "I can hear how upset you are. You sound very concerned about your mother."

ANS: 4. "I can hear how upset you are. You sound very concerned about your mother." Acknowledging the client's son's feelings is the most therapeutic intervention because he is not likely to hear the nurse's information until his anger and other feelings are addressed and subside. Then it is important to acknowledge that oxycontin, 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.

102. A 16-year-old boy who is academically gifted is about to graduate from high school early since he has completed all courses needed to earn a diploma. Within the last 3 months he has begun to experience panic attacks that have forced him to leave classes early and occasionally miss a day of school. He is concerned that these attacks may hinder his ability to pursue a college degree. What would be the best response by the school nurse who has been helping him deal with his panic attacks? 1. "It is natural to be worried about going into a new environment. I am sure with your abilities you will do well once you get settled." 2. "You are putting too much pressure on yourself. You just need to relax more and things will be alright." 3. "It might be best for you to postpone going to college. You need to get these panic attacks controlled first." 4. "It sounds like you have real concern about transitioning to college. I can refer you to a health care provider for assessment and treatment."

ANS: 4. "It sounds like you have real concern about transitioning to college. I can refer you to a health care provider for assessment and treatment." The client's concerns are real and serious enough to warrant assessment by a physician rather than being dismissed as trivial. Though he is very intelligent, his intelligence cannot overcome his anxiety, and in fact, his anxiety is likely to interfere with his ability to perform in college if no assessment and treatment is received. Just postponing college is likely to increase the client's anxiety rather than lower it since it does not address the panic he is experiencing.

27. The client with histrionic personality disorder is melodramatic and responds to others and situations in an exaggerated manner. The nurse should recommend which of the following activities for this client? 1. Party planning. 2. Music group. 3. Cooking class. 4. Role-playing.

ANS: 4. Role-playing. The nurse should use role-playing to teach the client appropriate responses to others in various situations. This client dramatizes events, draws attention to self, and is unaware of and does not deal with feelings. The nurse works to help the client clarify true feelings and learn to express them appropriately. Party planning, music group, and cooking class are therapeutic activities, but will not help the client specifically learn how to respond appropriately to others.