Ch. 36-NCLEX ch. 63
The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse would monitor for which symptoms?
Hypertension, disorientation, hallucinations
The nurse is caring for a client who is suspected of being dependent on drugs. Which question would be appropriate for the nurse to ask when collecting data from the client regarding drug abuse?
"How much do you use and what effect does it have on you?"
The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I need to get out of this bad situation." The most helpful response by the nurse would be which statement?
"What do you find difficult about this situation?"
The nurse is assigned to care for a client at risk for alcohol withdrawal. The client's spouse asks the nurse, "when will the first signs of withdrawal appear?" The nurse would give which reply?
"Within a few hours" * early as 6 hours and sometimes last 3-5 days
Which are the appropriate interventions for caring the client undergoing alcohol withdrawal? Select all that apply
-Monitor vital signs -Provide a safe environment -Address hallucinations therapeutically -Provide reality orientation as appropriate
The nursing student is creating a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents with intervention in the plan that is not specific to this disorder?
-Observe for excessive exercise
A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client would be appropriate choice as this client's roommate?
A client receiving diagnostic tests
A client who has been drinking alcohol on a regular basis admits to having "a problem" and is asking for assistance with the problem. The nurse would encourage the client to attend which community group?
Alcoholics anonymous
The nursing student is asked to identify the characteristics of bulimia nervosa. Which characteristic if identified by the student indicates a need to further research the disorder?
Body weight well below ideal range
A hospitalized client with a history of alcohol abuse 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. In fact, the client 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. Which is the appropriate nursing action?
Call the nursing supervisor
A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as which finding?
Evidence of the client's altered and distorted body image
The nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doing vigorous push-ups. Which nursing action is appropriate?
Interrupt the client and offer to take her for a walk
The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action?
Observing rigid rules and regulations
The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which manifestations are specifically associated with withdrawal from opioids?
Yawning, irritability, diaphoresis, cramps, and diarrhea
The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-anon group when the nurse hears the wife make which statement?
"I no longer feel that I deserve the beatings my husband inflicts on me"
