NUR 202 MOD A Quiz

Which client characteristic is an initial concern for the nurse when caring for a client with the diagnosis of paranoid schizophrenia?

Suspicious feelings The nurse must consider the client's suspicious feelings and establish basic trust to promote a therapeutic milieu.

When speaking with a client who has schizophrenia, the nurse notes that the client keeps interjecting sentences that have nothing to do with the main thoughts being expressed. The client asks whether the nurse understands. How should the nurse reply?

"I'd like to understand what you're saying, but I'm having trouble following you." lets the client know that the nurse is trying to understand; it increases the client's feeling of self-esteem and points out reality. Clients with schizophrenia have problems with associative links, and these same problems will occur regardless of the topic.

A client who is receiving chemotherapy for lung cancer has nausea and vomiting because of the therapy. The client wants to know if it is true that smoking marijuana will help. What is the nurse's best response?

"Tetrahydrocannabinol is an ingredient in marijuana that acts as an antiemetic in some people." Tetrahydrocannabinol, an ingredient in marijuana, acts as an antiemetic in some persons and can be absorbed through the gastrointestinal tract or inhaled.

A client is receiving carbamazepine (Tegretol) for the treatment of a manic episode of bipolar disorder. What should the nurse include when planning client teaching about this medication? Select all that apply.

"You may want to suck on hard candy when you get a dry mouth." "We'll need to test your blood often during the first few weeks of therapy." Sucking on hard candy or frequent rinsing may relieve a dry mouth, a side effect of carbamazepine. Carbamazepine can cause severe bone marrow depression in the early phase of therapy. Also, the drug level needs to be checked frequently to ensure a therapeutic level.

A 37-year-old man has been remanded by the court to the drug rehabilitation unit of a psychiatric facility for treatment of cocaine addiction. When taking his health history, what characteristics should the nurse expect the client to report? Select all that apply

Anxiety, Weight loss, Palpitations Cocaine, an alkaloid stimulant, can precipitate anxiety, hypervigilance, euphoria, agitation, and anger. The loss of appetite and increased metabolic rate associated with cocaine addiction both promote weight loss. Cocaine is a stimulant that has cardiac effects such as tachycardia and dysrhythmias.

The nurse is caring for a client who is now hospitalized in a rehabilitation unit for the third time for alcoholism. The nurse knows that some alcoholics relapse even though they attend AA meetings because they:

Are trying drastically to alter only a few long-standing habits associated with drinking To maintain sobriety, alcoholics must forever alter patterns of behavior that have been reinforced and used for prolonged periods.

A client is admitted to the hospital for acute gastritis and ascites secondary to alcoholism and cirrhosis. It is most important for the nurse to assess this client for

Blood in the stool Erosion of blood vessels may lead to hemorrhage, a life-threatening situation further complicated by decreased prothrombin production, which occurs with cirrhosis.

A nurse is working in a clinic that provides services to clients who abuse drugs. What effect of cocaine should the nurse consider as the reason that it easily causes dependence?

Blurs reality The addict tries to avoid stress and reality. The drug produces a blurring of these feelings to the point that the addict becomes dependent on it

How can a nurse best accomplish therapeutic communication with an adolescent?

By establishing a relationship over time Several meetings with an adolescent will provide an opportunity to develop trust and establish a relationship.

As a client addicted to cocaine withdraws from the drug, the nurse should expect to observe behavior related to

Depression There is no set of symptoms associated with cocaine withdrawal, only the depression that follows the high caused

A client is brought to the emergency department by friends because of increasingly bizarre behavior. Which signs does the nurse identify that indicate that the client was using cocaine? Select all that apply.

Euphoria Agitation Hypervigilance Impaired judgment

Nurses on a psychiatric unit have secluded a client who has the diagnosis of bipolar I disorder, manic episode, and who has been losing control and throwing objects while in the dayroom. The most important intervention for the client who is given a PRN medication and confined to involuntary seclusion is to:

Evaluate the client's progress toward self-control. For the safety of the client and everyone on the unit, improvement in a client's level of self-control is essential before the degree of restraint and seclusion is progressively reduced.

A nurse is caring for a client with a bipolar disorder depressive episode. What should the nurse's objective for this client be?

Feeling comfortable with the nurse Before therapy can begin, a trusting relationship must be developed.

A 45-year-old man who recently completed alcohol detoxification states that he plans to begin using disulfiram (Antabuse) as part of his alcoholism treatment regimen. Important client teaching by the nurse regarding this drug is that:

Foods, medications, and any topical preparation containing alcohol should be avoided Disulfiram causes unpleasant physical effects when mixed with alcohol. Any substance that contains alcohol may trigger an adverse reaction.

A client with the diagnosis of schizophrenia refuses to eat meals. Which nursing action is most beneficial for this client?

Having a staff member sit with the client in a quiet area during mealtimes By sitting with the client during mealtimes the nurse can evaluate how much the client is eating; this encourages the client to eat and begins the construction of a trusting relationship

A client has been found to have bipolar disorder and is being prescribed lithium carbonate (Lithium). In light of the information shown, the nurse provides teaching to the client. Select all that apply.

Her current thyroid function will require frequent assessments while she takes lithium Hyponatrium could lead to lithium toxicity, so the healthcare provider must first be notified of the level Lithium carbonate therapy can negatively affect thyroid function; the client's current TSH is at the high normal level and so frequent checks are appropriate. Low serum sodium levels would result in the kidneys' reabsorbing the lithium; this situation would lead to lithium toxicity.

A client is admitted with a diagnosis of premature labor. The nurse discovers that the client has been using heroin throughout her pregnancy. What is the most appropriate action for the nurse to take?

Inform the client's healthcare provider The fetus of a heroin-addicted mother is at risk for serious complications such as hypoxia and meconium aspiration. It is important to notify the healthcare provider of the client's heroin use, because this information will influence the care of the client and newborn. This information is used only in relation to the client's care. With the client's consent, it may be shared with other social service or health agencies that become involved with the client's long-term care.

A client with a history of alcoholism is found to have Wernicke encephalopathy associated with Korsakoff syndrome. What does the nurse anticipate will be prescribed?

Intramuscular injections of thiamine Thiamine is a coenzyme necessary for the production of energy from glucose. If thiamine is not present in adequate amounts, nerve activity is diminished and damage or degeneration of myelin sheaths occurs.

A nurse is admitting a client to the unit. What interaction demonstrates effective therapeutic communication principles?

Maintaining a distance of at least 3 feet from the clien Respecting personal space is a basic principle of therapeutic communication. A separation of 3 to 6 feet is considered appropriate and comfortable for nurse-client conversations

The home care nurse visits a child in whom failure to thrive has been diagnosed and makes observations that lead the nurse to suspect that the house is being used as a methamphetamine laboratory. Which observations support this conclusion? Select all that apply.

Many small plastic bags, A strong odor of acetone, Jars containing bright-yellow crystals Methamphetamine is often packaged in small plastic bags for sale. An odor of acetone may be produced in the process of making methamphetamine. The pseudoephedrine in cold medicine is used in the production of methamphetamine. Methamphetamine may appear as yellow crystals.

A female adolescent in group therapy tells the other group members that while out on a pass she used marijuana because her boyfriend made her smoke it. What defense mechanism is the client using?

Projection Projection involves blaming others for one's own difficulties or behaviors.

A nurse is caring for a client with bipolar I disorder. What should the plan of care for this client include? Select all that apply.

Providing a structured environment for the client Ensuring that the client's nutritional needs are met Structure tends to decrease agitation and anxiety and to increase the client's feelings of security. Whether the individual is experiencing mania or depression, nutritional needs must be met.

An adult with the diagnosis of schizophrenia is admitted to the psychiatric hospital. The client is ungroomed, appears to be hearing voices, is withdrawn, and has not spoken to anyone for several days. What should the nurse do during the first few hospital days?

Seek out the client frequently to spend short periods of time together

A client with a history of methamphetamine use is admitted to the mental health unit because of aggressive violent behavior. For what clinical manifestations of methamphetamine use should the nurse assess this client? Select all that apply.

Tachycardia Hyperthermia Methamphetamine is a stimulant that causes a surge of dopamine and blocks the reuptake of dopamine. The sympathetic nervous system is activated, resulting in an increase in the heart rate. Because methamphetamine affects the central nervous system, the body temperature will increase, sometimes to dangerous levels.

A client with the diagnosis of schizophrenia is given one of the antipsychotic drugs. The nurse understands that antipsychotic drugs can cause extrapyramidal side effects. Which effect is cause for the greatest concern?

Tardive dyskinesia Tardive dyskinesia, an extrapyramidal response characterized by vermicular movements and protrusion of the tongue, chewing and puckering movements of the mouth, and puffing of the cheeks, is often irreversible, even when the antipsychotic medication is withdrawn.

A client with paranoid schizophrenia tells the nurse, "My neighbors are spying on me because they want to rob me and take money." While hospitalized, the client complains of being poisoned by the food and of being given the wrong medication. The nurse evaluates the client's response to medications and therapy. Which assessment finding leads the nurse to conclude that the client's reality testing has improved?

The client eats the food provided on the hospital tray Because the client was admitted while complaining that the food was poisoned, eating the food on the tray indicates that the client feels safe.

A nurse is managing the care of a client with recently diagnosed schizophrenia. Effective therapeutic communication will directly affect which client-focused outcomes? Select all that apply.

The client will effectively express emotional and physical needs. The client will demonstrate an understanding of the mental health disorder The client will recognize the issues most important to managing this disorder.

When communicating with a client with a psychiatric diagnosis, the nurse uses silence. When silence is used in therapeutic communication, clients should feel:

There is no hurry to answer. Silence is a tool employed during therapeutic communication that indicates that the nurse is listening and receptive; it allows the client time to collect thoughts, gain control of emotions, or speak without hurrying.

What is the planned effect of naloxone when it is administered for a heroin overdose?

To compete with opioids for receptors that control respiration Naloxone is used to treat opioid-induced apnea. It competes with the opioid for central nervous system receptor sites and thus acts as an opioid antagonist

A client with a history of chronic alcoholism was admitted to a surgical unit after surgery to repair a severely fractured right ankle. The nurse is concerned that the client is experiencing manifestations of acute alcohol withdrawal when certain documentation and assessment data from the last 6 hours seem to indicate this problem. Select all that apply.

Tremors in both hands make it difficult for the client to hold a cup. The client's bed linens and pajamas had to be changed during the night as a result of increased diaphoresis. The usually cooperative client becomes verbally abusive when asked to lower the volume of the television. Agitation is a psychosocial characteristic of alcohol withdrawal. Diaphoresis and tremors are physical characteristics of alcohol withdrawal.

A client with the diagnosis of manic episode of bipolar disorder attends a mental health day treatment program. What supervised activity will be most therapeutic for this client during the early phase of treatment?

Walking around the facility with a nurse Walking around the facility with a nurse does not involve an element of competition and still allows the client to channel excess energy safely.