PSYC 3 BP

Anorexia Nervosa pt have difficultly expressing negative thoughts and conflicts especially

anger

a deals with issues of control and a struggle between dependence and independence

anoerxia

Unclear boundaries between family member associated with

anorexia

Overwhelming sense of guilt and anger, which leads to conflict avoidance

anorexia and bulimia

Tend to avoid conflict and have difficulty expressing negative emotions, especially anger

anorexia and bulimia

distorted body image associated with

anorexic usually see self as fat

programs harm reduction

any program you RECOGNIZE the problem and do something about unlike just abstinence More compassionate drug treatment options, including abstinence and drug substitution models; HIV-related interventions such as needle exchanges; directed drug-use management should the clientwish to continue use; changes in laws concerning possession of paraphernalia and drug use.

short term outcome for Anorexia Nervosa

bad long term better

enmeshment

between two or more people in which personal boundaries are permeable and unclear. This often happens on an emotional level in which two people "feel" each other's emotions, or when one person becomes emotionally escalated and the other family member does as well

body dissatisfaction seen in? body distortion seen in

body dissatisfaction seen in bulimia body distortion seen in anorexia

a deals with loss of control and guilt

bulimia a deals with loss of control (binge eating) and guilt (purging).

Wernicke's encephalopathy caused by

chronic alcohol abuse that results from thiamine deficieny

• Most inhalants are

common household or industrial products

A patient has been taking naltrexone (ReVia) as part of the treatment for addiction to heroin. The nurse expects that the naltrexone will have which therapeutic effect for this patient? A. Naltrexone prevents the cravings for opioid drugs. B. Naltrexone works as a safer substitute for the heroin until the patient completes withdrawal. C. The patient will experience flushing, sweating, and severe nausea if he takes heroin while on naltrexone. D. If opioid drugs are used while taking naltrexone, euphoria is not produced; thus, the drug's effects are lost.

d. if opioid drugs are used while taking naltrexone, euphoria is not produced; thus, the drug's effects are lost.

Overprotectiveness

detrimental to children at high risk for anorexia nervosa. The parents' overprotectiveness retards the child's development of autonomy and competence.

Cholinergic crisis

diaphoresis, diarrhea, fasciculations, cramps, marked worsening of symptoms resulting from overmedicatio

Naltrexone used for

drinking and opioid resistence ● Reduces craving, helps maintain abstinence, it can interfere w/ the tendency to want to drink more if recovering patient slips and has a drink.

An important predictor of anorexia nervosa is

early-onset menses, as early as 10 or 11 yrs of age.

A nurse is caring for a client who is experiencing alcohol withdrawal. Which assessment finding indicates the need for an as-needed dose of chlordiazepoxide? a) Blood pressure of 100/70 mm Hg b) Blood pressure of 140/80 mm Hg c) Heart rate of 50 to 60 beats/minute d) Heart rate of 120 to 140 beats/minute

eart rate of 120 to 140 beats/minute Correct Explanation: Tachycardia, a heart rate of 120 to 140 beats/minute, is a common sign of alcohol withdrawal. This finding indicates the need for a central nervous system depressant, which may prevent progression of alcohol withdrawal. Blood pressure may be labile throughout withdrawal, fluctuating at different stages. Hypertension typically occurs in early withdrawal. Hypotension, although rare during the early withdrawal stages, may occur in later stages. Hypotension is associated with cardiovascular collapse and most commonly occurs in clients who don't receive treatment. The nurse should carefully monitor the client's vital signs throughout the entire alcohol withdrawal process. (less)

refeeding what is not allowed

exercise

FRAMES

feedback, responsibility, advice, menu of strategies, empathy, and self-efficacy) summarizes elements of *brief interventions* with patients using *motivational interviewing*

RN approach to person with anorexia

firm accepting provide rationale non reactive-consistence

the rx for anorxia and belimia is

fluoxetine a SSRI-

when should you use brief intervention

for low risk pt Are experiencing few problems with their drug use • Have low levels of dependence • Have a short history of drug use • Have stable backgrounds • Are unsure or ambivalent about changing or ending their drug use

ear acupressure used to

helpp quit smoking Auricular therapy

• Naloxone (Narcan) - opioid antagonist o Given to reverse the side effects

heroine overdose o Given to reverse the side effects of: Respiratory depression Sedation HTN

If an adult has experienced abuse/neglect as a child, he or she is vulnerable to development of what disorder

hey are at risk for depression, anxiety, low self-esteem, and substance abuse.

Bupropion Wellbutrin can cause

increase in anxiety

Ritalin is the drug of choice for children with ADHD. The side effects of the following may be noted:

increased attention span and concentration

Nitrites

inhalants enhance sexualized pleasure o Dilate and relax blood vessels

sleep latency

is the amount of time it takes to fall asleep after the lights have been turned off.

Night Eating Syndrome pt feels

loss of control over consumption, sleep fragmentation, and morning anorexia is felt by the patient.

A nurse is caring for a client undergoing opiate withdrawal, which causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with: a) barbiturates. b) methadone. c) benzodiazepines. d) amphetamines.

methadone. Correct Explanation: - Methadone is used to detoxify opiate users because it binds with opioid receptors at many sites in the central nervous system but doesn't have the same deleterious effects as such opiates as cocaine, heroin, and morphine. - Barbiturates, amphetamines, and benzodiazepines are highly addictive and using these drugs would make detoxification treatment necessary

to get the % of blood alchol you

mg/1000 do 70mg= .07

athletes are more or less likely to develop eating disorder?

more

the best way to intervene with a client's minimization or denial of alcohol problems

ms is to point out the consequences of the drinking—the

why is anorexia and bulimia isolated

o Because of the ritualistic behaviors, an all-encompassing focus on food and weight, and feelings of inadequacy, social contacts are gradually reduced, so that the patient becomes isolated

what do e cigs do

o Delivers highly addictive nicotine o Safety and effectiveness -----> questionable

• Use of medications for those recovering aa

o Disulfiram (Antabuse) - used as adjunct therapy for alcoholism/dependence o Naltrexone - treatment for dependence and heroin abuse

• Severe dementia

o Gait and motor disturbances o Bedridden o Unable to perform ADLs o Incontinence o Requires long-term care placement

Gambling disorder Has 4 phases

o Highly competitive o Energetic o Restless o Easily bored

• Moderate dementia

o Inability to retain new info o Behavioral, personality changes o Increasing long-term memory loss o Wandering, agitation, aggression, confusion o Requires assistance with ADLs

• Techniques that enhance motivation are associated with

o Increased success in treatment o Higher rates of abstinence o Successful follow-up treatment

• Mild dementia

o Loss of memory o Language difficulties o Mood swings o Diminished judgment o Apathy

what is a brief intervention

o Negotiated conversation between the professional and patient o Designed to reduce or eliminate alcohol and drug use

• Patients with delirium have

o Reduced ability to focus o Difficulty in sustaining or shifting attention o Changes in cognition o Perceptual disturbances

Binge Eating Disorder are usually

obese

most people with binge-eating disorde are

obese

belimia people are usually 5

overwhelmed overly committed social butterflies who have difficulty setting limits and establishing appropriate boundaries high levels of impulsivity, financial and legal difficulties

is characteristic of both anorexia nervosa and bulimia nervosa; hypothesized to develop long before eating disorders occur. The more severe the disorder the more perfectionist.

perfectionism

People with anorexia gain pleasure from

providing others with food and watching them eat. These behaviors reinforce their perception of self-control. Do not allow these clients to plan or prepare food for unitbased activities.

most important intervention ppl with eating disorders

setting realistic goals

leading cause of death among people with Anorexia Nervosa

suicide

bupropion (Wellbutrin should watch for a/e

suicide though seizure weight loss sleep disturbance

fluoxetine teaching points 2

taken in morning and cause weight LOSS in few week follow by weight gain!

cycle of violence

tension-building phase, battering incident, and honeymoon phas

harm reduction recognize that

the ideal is abstinence

The long-term goal AUTISM

the patient to achieve the highest level of functioning.

Korsakoff Amnestic Syndrome

the primary problem is acquiring new information and retrieving memories. S/S→ amnesia, confabulation, attention deficit, disorientation, and vision impairment thiamine deficiency, i

Bupropion Wellbutrin used

to help people quit and is antidepress

• Naltrexone (Revia)

to prevent relapse into alcohol abuse

• Disulfiram (Antabuse)

to prevent relapse into alcohol abuse (the client must be alcohol-free for 12 hours before administering this drug) • Used as an adjunct therapy

Human and animal studies confirm a genetic predisposition for drinking behaviors and self-administering mind-altering drugs, but as yet no precise genetic marker has been established.

true

Anorexia Nervosa: Age of Onset

typically) 14-16yo

varenicline tartrate

used to stop smoking

when to teach pt with anorexia

when weight is gained> concentration imprived

Anyone that is injected with Narcan

will become hypervigilant and is not associated with alcohol use.

Buprenorphine-aided opiate

withdrawal is initiated after the patient begins showing symptoms of withdrawal. This is necessary because buprenorphine is a partial opiate agonist (partially stimulates the receptor) and may induce significant withdrawal symptoms if other full agonist

o Impaired judgment o Giddiness o Mood changes

• 0.05

o Difficulty driving o Difficulty coordinating movements

• 0.10

o Motor function severely impaired o Ataxia o Emotional lability

• 0.20

o Stupor o Disorientation/confusion

• 0.30

Chronic Drinkers - Withdrawals

• 12-hr after abrupt discontinuation or attempt to decrease consumption • Delirium tremors (most severe symptom) o Acute withdrawal syndrome Autonomic hyperarousal Disorientation Hallucination Tremors • Grand Mal (tonic-clonic) seizures ----> priority nursing intervention o If occurs, usually within 1st 48 hours of withdrawal

in Gambling disorder actions are

• Action of seeking an aroused state o More important than the money itself

Wernicke-Korsakoff Syndrome

• Combination of Wernicke Encephalopathy and Korsakoff Amnestic Syndrome o Each one occurs as a different stage Wernicke's Encephalopathy ----> acute phase Korsakoff Amnestic Syndrome ----> chronic phase

codependency looked at as

• Described as "enabling" goal: Person must recognize own problem

ipecac which is disorder

• Individuals with bulimia often use syrup of ipecac to induce vomiting. If ipecac is not vomited and is absorbed, cardiotoxicity may occur and can cause conduction disturbances, cardiac dysrhythmias, fatal myocarditis, and circulatory failure. Because heart failure is not usually seen in this age group, it is often overlooked. Assess for edema and listen to breath sounds.

Sniffing Death

• Occurs when the inhaled fumes replace oxygen in the lungs and NS

A client with Alzheimer's disease is started on a low dose of lorazepam (Ativan) because of agitation and a sleep disturbance. The nurse should assess the client for which of the following? ■ 1. Nighttime agitation. ■ 2. Extrapyramidal side effects. ■ 3. Vomiting. ■ 4. Anticholinergic side effects

■ 1. Nighttime agitation.

Managing Catastrophic Reactions:

○ Remain calm ○ Minimize environmental distractions (quite the environment) ○ Get the patient's attention ○ Softly assure the patient that he/she is safe ○ Give information slowly, clearly, and simply, one step at a time ○ Let the patient know that you understand the fear or other emotional response (such as anger or anxiety)

Characteristic of anorexia nervosa

○ decreased interoceptive awareness cant feel inside-emotion and hunger cues ○ sexuality conflict of fears ○ maturity fears ○ ritualistic behaviors ○ feelings of inadequacy a

Bulimia Nervosa characteritic 4

○ impulsivity ○ boundary problems ○ limit-setting behaviors ○ little or no weight loss occurs (unlike anorexia nervosa)

Night Eating Syndrome cause

● Conceptualized as a disorder of circadian modulation of food intake and sleep. Mainly attributed to a endocrinal, metabolic, or psychologic trigger. ● Typically experience insomnia and nighttime awakenings.

Bulimia Nervosa dx

● Episodes occur at least once a week for a period of at least 3mo

binge-eating disorder?

● Individuals binge in the same way as those w/bulimia nervosa but DO NOT PURGE OR COMPENSATE FOR BINGES through other behaviors (unlike bulimia nervosa).

Confabulation

● Telling a plausible but imagined scenario to compensate for memory loss

Tolerance

● The ability to ingest an increasing amount of alcohol before experiencing a "high" and showing cognitive and motor effects. ● The locus ceruleus o Inhibits the action of alcohol o Believed to be instrumental in the development of alcohol tolerance

Perfectionism seen in

● symptoms of both anorexia nervosa and bulimia nervosa

Alcohol Withdrawal Syndrome

● symptoms of ↑HR & BP, diaphoresis, mild anxiety, restlessness, hand tremors **It is important to observe for signs of seizure**

A client is in the emergency department after a motor vehicle crash that involved alcohol use. Which statement is true about harm reduction? 1. The client must admit he is an alcoholic before he can decrease his intake. 2. The client must abstain and agree to attend a 12-step program. 3. The nurse can help the client plan ways to prevent a reoccurrence. 4. This nurse needs to confront the client's denial of the problem.

(4) This is an excellent opportunity to help the client recognize the use Of alcohol and the Current situation. Often, due to denial, the client cannot connect the use of alcohol and the accident. The client can then decide upon a plan to pre- vent a future accident. Labeling the client as an alcoholic will result in the client becoming defensive. Some people are able to reduce their intake, while others need to abstain. The client will be more receptive to reduction than abstinence.

Encourage the use of a pacifier to meet sucking needs

(in cases of heroin withdrawal

An intoxicated patient smells of alcohol and reports consuming two 12 oz. beers per day. Which of the following pieces of information suggests that the patient is underreporting his alcohol consumption? Select all that apply

) Patient has elevated liver enzymes; AST is approximately two times ALT B) Patient develops tremors eight hours after admission C) Patient has a seizure 24 hours after admission D) Patient becomes hypervigilant after injection with naloxone (Narcan) E) Patient has hallucinations 48 hours after admission F) Patient has a blood alcohol level of 70 mg/dl Answer ABCE - Elevated liver enzymes can be due to a number of insults to the liver, alcohol use being one of them. Patients with alcoholism classically have a 2:1 ratio of AST to ALT. Tremors, seizures and hallucinations are all signs/symptoms of alcohol withdrawal in someone that is dependant. They occur at different times after the last alcoholic beverage is consumed and the times in the question are reasonable for each behavior. Narcan blocks opioid receptors and is used to reverse heroin or other opioid intoxication/overdose. Anyone that is injected with Narcan will become hypervigilant and is not associated with alcohol use. A blood alcohol level of 70 mg/dl is roughly equivalent to a blood alcohol concentration of 0.07%, which would be in keeping with his report of drinking two beers a day

Before Joan has the prescription for bupropion (Wellbutrin XL) filled, the nurse should ensure that the client has not experienced whihc problem(s)? (Select all

-Seizures -Anorexia or bulimia Lowers seizure threshold; should not be used for patients with seizure disorders or eating disorders because of increased seizure incidence in this group.

A school nurse is planning a program for parents on "Drugs Commonly Abused by Teenagers". Which of the following information should be included about inhalants? Select all that apply. ■ 1. Monitor for paper bags and rags that may have been used for breathing inhalants. ■ 2. Brain damage is unlikely with the use of inhalants. ■ 3. Use of inhalants by teens is on the decline. ■ 4. Deaths from inhalants occur from asphyxiation, suffocation, and aspiration of vomit. ■ 5. Inhalants usually cause depression of the central nervous system. ■ 6. The basic groups of inhalants are hydrocarbon solvents such as glue, aerosol propellants from spray cans, and anesthetics/gases

. 1, 4, 5, 6. The nurse should instruct the parents to monitor their children for use of paper bags or rags. The nurse should present information about brain damage from inhalants including damage to the frontal lobe, cerebellum, and hippocampus, and that death is possible. Rather than use being on the decline, teenagers are experimenting even more with many types of inhalants, such as Freon, ground-up candy disks, and spray cleaners for computer and TV screens

A 10-year-old diagnosed with attention defi cit hyperactivity disorder (ADHD) has been switched from a stimulant to atomoxetine (Strattera) 40 mg two times a day. The nurse is instructing the client and her mother about the change in medication. Which statement indicates that the client's mother needs further education about the medication? Select all that apply. ■ 1. "I have to give her both doses before lunch." ■ 2. "I'll have to make sure she's gaining weight appropriately." ■ 3. "She may have nausea or dizziness for 1 or 2 months." ■ 4. "If she has mood swings, I should call her psychiatrist." ■ 5. "She can't take monoamine oxidase inhibitors while on Strattera." ■ 6. "If her ADHD symptoms don't improve in 2 to 3 weeks, I should stop the Strattera."

. 1, 6. Atomoxetine is a selective norepinephrine reuptake inhibitor antidepressant, not a stimulant. Therefore, a two-times-a-day dosing schedule is appropriate, with a dose given in the morning and late afternoon. It may take more than 2 to 3 weeks to see the full effects of this medication. Nausea and dizziness are transient side effects. Monoamine oxidase inhibitors are contraindicated with atomoxetine

54. The client sees no connection between her liver disorder and her alcohol intake. She believes that she drinks very little and that her family is making something out of nothing. The nurse interprets these behaviors as indicative of the client's use of which of the following defense mechanisms? ■ 1. Denial. ■ 2. Displacement. ■ 3. Rationalization. ■ 4. Reaction formation.

. 1. The client is using denial, an unconscious defense mechanism, when she refuses to acknowledge that she has a problem with alcohol. This is further evidenced by the client's inability to connect the liver disorder with alcohol ingestion. Displacement involves transfer of a feeling to someone else or to an object. Rationalization involves an attempt to make or prove that one's feeling or behavior is justifi able. Reaction formation is a conscious behavior that is the exact opposite of an unconscious

The term motor apraxia relates to a decline in motor patterns essential for complex motor tasks. However, the client with severe dementia may be able to perform which of the following actions? ■ 1. Balance a checkbook accurately. ■ 2. Brush the teeth when handed a toothbrush. ■ 3. Use confabulation when telling a story. ■ 4. Find misplaced car keys

. 2. Highly conditioned motor skills, such as brushing the teeth, may be retained by the client who has dementia and motor apraxia. Balancing a checkbook involves calculations, a complex skill that is lost with severe dementia. Confabulation is fabrication of details to fi ll a memory gap. This is more common when the client is aware of a memory problem, not when dementia is severe. Finding keys is a memory factor, not a motor function

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."

. 2. 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.

113. The nurse discusses the possibility of a client's attending day treatment for clients with early Alzheimer's disease. Which of the following is the best rationale for encouraging day treatment? ■ 1. The client would have more structure to his day. ■ 2. Staff are excellent in the treatment they offer clients. ■ 3. The client would benefi t from increased social interaction. ■ 4. The family would have more time to engage in their daily activitie

. 3. The client would benefi t from increased social interaction The best rationale for day treatment for the client with Alzheimer's disease is the enhancement of social interactions. More daily structure, excellent staff, and allowing caregivers more time for themselves are all positive aspects, but they are less focused on the client's needs.

66. A client is being admitted to the hospital following an inadvertent overdose with hydrocodone (Vicodin). He reveals that he has chronic back pain which resulted from an injury on a construction site. He states, "I know I took too much Vicodin at once, but I can't live with this pain without them. You can't take them away from me." Which of the following responses by the nurse is most appropriate? ■ 1. "Once you are tapered off the Vicodin, you will fi nd that non-addictive pain medicines will be enough to control your pain." ■ 2. "You are going to be switched from the Vicodin to methadone (Dolophine) for long-term pain management. ■ 3. The Vicodin will be stopped tomorrow, but you will have lorazepam (Ativan) to help you with the withdrawal symptoms. ■ 4. Your pain will be controlled by tapering doses of propoxyphene (Darvon-N), with other pain management strategies and medicines.

. 4. Tapering doses of Darvon-N, pain management strategies, and other pain control medicines are found to be the most helpful with opiate addictions resulting from chronic pain. Non-addictive (overthe-counter medicines) alone are generally insuf- fi cient for chronic pain management. Methadone is an addictive opioid which involves substituting one addiction with another, so now clients are being detoxed off Methadone as well. Ativan may help with anxiety during withdrawal from opiates, but it does not control the other symptoms of opiate withdraw

44. Which of the following statements by the nurse participating in a group confrontation of a coworker is most helpful in reducing the coworker's denial about alcohol being a problem? ■ 1. "Your behavior is unprofessional." ■ 2. "As a nurse you should have sought help earlier." ■ 3. "Nurses are the worst when it comes to asking for help." ■ 4. "You have alcohol on your breath."

. 4. To be most helpful, the nurse should calmly and objectively present facts by saying, "You have alcohol on your breath," to help the coworker overcome denial and resistance. This statement also helps to reinforce the coworker's awareness of the problem. The other statements blame the coworker and may reinforce denial. Blaming, nagging, and yelling diminish self-esteem in the individual with a substance abuse problem who has low frustration

A nurse works with a client diagnosed with bulimia. What is an appropriate long-term client goal for this client? ■ 1. Eating meals at home without bingeing or purging. ■ 2. Being able to eat out without bingeing or purging. ■ 3. Managing stresses in life without bingeing or purging. ■ 4. Being able to attend college in a

. A successful outcome for a bulimic client is to avoid using the eating disorder as a coping measure when dealing with stress. Being able to attend college in another state, eat at home, and eat out without bingeing and purging are important goals, but do not address the primary problem of stress management and its connection to eating.

coma at what blood achol level

.40

o Respiratory failure o Death

.50

When caring for a client with myasthenia gravis who is receiving anticholinesterase drug therapy, the nurse must be able to distinguish cholinergic crisis from myasthenic crisis. Which of the following symptoms is not present in cholinergic crisis? ■ 1. Improved muscle strength after I.V. administration of edrophonium chloride (Tensilon). ■ 2. Increased weakness. ■ 3. Diaphoresis. ■ 4. Increased salivation

1 1. Extreme muscle weakness is present in both cholinergic crisis and myasthenic crisis. In cholinergic crisis, I.V. edrophonium chloride (Tensilon), a cholinergic agent, does not improve muscle weakness; in myasthenic crisis, it does. Diaphoresis and increased salivation are not present in cholinergic crises.

A nurse is working with a client with bulimia. Which of the following goals should be included in the care plan? Select all that apply. ■ 1. The client will maintain normal weight. ■ 2. The client will comply with medication therapy. ■ 3. The client will achieve a positive selfconcept. ■ 4. The client will acknowledge the disorder. ■ 5. The client will never have the desire to purge

1, 2, 3, 4. Because of the large number of calories ingested in a binge and the fact that a purge does not eliminate all calories consumed, the client with bulimia is of more normal weight, but still must have a goal of maintaining that weight. Research has shown that selective serotonin reuptake inhibitors are effective in treating bulimia, and the client is usually amenable to taking the medication. The client with an eating disorder (bulimia and anorexia) has negative self-concepts that fuel her disordered eating, and attaining a positive self-concept is an appropriate goal. The nurse should work with the client with bulimia to help her recognize her eating as disordered. That recognition can make the client more amenable to treatment. It is not realistic to establish a goal that the client with bulimia will never have the desire to purge again

A client is brought to the emergency department by a friend who states, "He's been using a lot of heroin until he ran out of money about 2 days ago." The nurse judges the client to be in opioid withdrawal if he exhibits which of the following? Select all that apply. ■ 1. Rhinorrhea. ■ 2. Diaphoresis. ■ 3. Piloerection. ■ 4. Synesthesia. ■ 5. Formication.

1, 2, 3. Symptoms of opioid withdrawal include yawning, rhinorrhea, sweating, chills, piloerection (goose bumps), tremors, restlessness, irritability,leg spasms, bone pain, diarrhea, and vomiting. Symptoms of withdrawal occur within 36 to 72 hours of usage and subside within a week. Withdrawal from heroin is seldom fatal and usually does not necessitate medical intervention. Synesthesia (a blending of senses) is associated with lysergic acid diethylamide use, and formication (feeling of bugs crawling beneath the skin) is associated with cocaine use.

An 83-year-old woman is admitted to the unit after being examined in the emergency department (ED) and diagnosed with delirium. After the admission interviews with the client and her grandson, the nurse explains that there will be more laboratory tests and X-rays done that day. The grandson says, "She has already been stuck several times and had a brain scan or something. Just give her some medicine and let her rest." The nurse should tell the grandson which of the following? Select all that apply. ■ 1. "I agree she needs to rest, but there is no one specifi c medicine for your grandmother's condition." ■ 2. "The doctor will look at the results of those tests in the ED and decide what other tests are needed." ■ 3. "Delirium commonly results from underlying medical causes that we need to identify and correct." ■ 4. "Tell me about your grandmother's behaviors and maybe I could fi gure out what medicine she needs." ■ 5. "I'll ask the doctor to postpone more tests until tomorrow."

1, 2, 3. The client does need rest and it is true that there is no specifi c medicine for delirium, but it is crucial to identify and treat the underlying causes of delirium. Other tests will be based on the results of already completed tests. Although some medications may be prescribed to help the client with her behaviors, this is not the primary basis for medication orders. Because the underlying medical causes of delirium could be fatal, treatment must be initiated as soon as possible. It is not the nurse's role to determine medications for this client. Postponing tests until the next day is inappropriat

The nurse is planning an eating disorder protocol for hospitalized clients experiencing bulimia and anorexia. Which elements should be included in the protocol? Select all that apply. ■ 1. Clients must eat within view of a staff member. ■ 2. Clients are not told their weight and cannot see their weight while being weighed. ■ 3. Clients are not allowed to discuss food or eating in groups or informal conversation with peers. ■ 4. Clients must rest within view of a staff member and not go to the bathroom for one half hour to an hour after eating. ■ 5. Clients cannot participate in any groups after admission until they gain 1 lb.

1, 2, 4. In hospital settings, clients are not allowed to know their weight at the time they are being weighed to decrease obsessing about weight gain. They must also eat and rest in staff view and cannot use the bathroom for a period to prevent discarding food or vomiting ingested food (purging). The rest prevents the client from exercising off the calories they just consumed. Barring clients from ever talking about food or attending groups until they have gained weight diminishes the therapeutic value of the inpatient hospital stay. CN: Psychosocial adaptation;

The friend of a client brought to the emergency department states, "I guess she had some bad junk (heroin) today." The client is drowsy and verbally nonresponsive. Which of the following assessment fi ndings is of immediate concern to the nurse? ■ 1. Respiratory rate of 9 breaths/minute. ■ 2. Urinary retention. ■ 3. Hypotension. ■ 4. Reduced pupil size

1. A respiratory rate of less than 12 breaths/ minute is cause for concern because of central nervous system depression. Respiratory depression and arrest is the primary cause of death among clients who abuse opioids. Peripheral nervous system effects associated with opioid abuse include urinary retention, hypotension, reduced pupil size, constipation, and decreased gastric, biliary, and pancreatic secretions. Pinpoint pupils are a sign of opioid overdose. However, respiratory depression is the immediate concern.

122. The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following signifi cant side effects to the health care provider? ■ 1. Paradoxical excitement. ■ 2. Headache. ■ 3. Slowing of refl exes. ■ 4. Fatigue.

1. Although all of the side effects listed are possible with Ativan, paradoxical excitement is cause for immediate discontinuation of the medication. (Paradoxical excitement is the opposite reaction to Ativan than is expected.) The other side effects tend to be minor and usually are transient.

114. When developing the plan of care for a client with Alzheimer's disease who is experiencing moderate impairment, which of the following types of care should the nurse expect to include? ■ 1. Prompting and guiding activities of daily living. ■ 2. Managing a medication schedule. ■ 3. Constant supervision and total care. ■ 4. Supervision of risky activities such as shaving

1. Considerable assistance is associated with moderate impairment when the client cannot make decisions but can follow directions. Managing medications is needed even in mild impairment. Constant care is needed in the terminal phase, when the client cannot follow directions. Supervision of shaving is appropriate with mild impairment—that is, when the client still has motor function but lacks judgment about safety issues

92. The nurse is attempting to draw blood from a woman with a diagnosis of delirium who was admitted last evening. The client yells out, "Stop; leave me alone. What are you trying to do to me? What's happening to me?" Which response by the nurse is most appropriate? ■ 1. "The tests of your blood will help us fi gure out what is happening to you." ■ 2. "Please hold still so I don't have to stick you a second time." ■ 3. "After I get your blood, I'll get some medicine to help you calm down." ■ 4. "I'll tell you everything after I get your blood tests to the laboratory."

1. Explaining why blood is being taken responds to the client's concerns or fears about what is happening to her. Threatening more pain or promising to explain later ignores or postpones meeting the client's need for information. The client's statements do not refl ect loss of self control requiring medication intervention

95. In addition to developing over a period of hours or days, the nurse should assess delirium as distinguishable by which of the following characteristics? ■ 1. Disturbances in cognition and consciousness that fl uctuate during the day. ■ 2. The failure to identify objects despite intact sensory functions. ■ 3. Signifi cant impairment in social or occupational functioning over time. ■ 4. Memory impairme

1. Fluctuating symptoms are characteristic of delirium. The failure to identify objects despite intact sensory functions, signifi cant impairment in social or occupational functioning over time, and memory impairment to the degree of being called amnesia all indicate dementia.

49. Which of the following nursing actions is contraindicated for the client who is experiencing severe symptoms of alcohol withdrawal? ■ 1. Helping the client walk. ■ 2. Monitoring intake and output. ■ 3. Assessing vital signs. ■ 4. Using short, concrete statements

1. Having the client who is experiencing severe symptoms of alcohol withdrawal walk is contraindicated because increased activity and stimulation may confuse the client and promote hallucinations. The client may also sustain an injury if he has a seizure as part of the alcohol withdrawal process. The nurse should monitor intake and output to ensure fl uid and electrolyte balance and hydration. The nurse should assess vital signs to assess the physiologic status of the client and the response to medications. The nurse should use short, concrete statements to decrease confusion and ambiguity

146. A client is experiencing symptoms of early alcohol withdrawal. The client's blood pressure is 150/85 mm Hg and the pulse is 98 bpm. The nurse should: ■ 1. Administer lorazepam (Ativan). ■ 2. Apply arm and leg restraints. ■ 3. Assign an unlicensed assistive personnel to sit with the client. ■ 4. Notify the physician.

1. Lorazepam (Ativan), a benzodiazepine, is commonly used to decrease the symptoms of central nervous system irritability in the client who is experiencing early symptoms of alcohol withdrawal. There is no indication that restraints are needed at this time. If the lorazepam is effective, it will not be necessary to have someone sit with the client. At this point, it is not necessary to notify the physician.

A client who comes to the emergency department with multiple bruises on her face and arms, a black eye, and a broken nose says that these injuries occurred when she fell down the stairs. The nurse suspects that the client may have been physically assaulted. Which of the following should the nurse do next? ■ 1. Ask the client specifi cally about the possibility of physical abuse. ■ 2. Tell the client that it is diffi cult to believe that such injuries resulted from a fall. ■ 3. Ask the client what she did to make someone beat her so badly. ■ 4. Discuss with the client what she can do to deescalate the situation next time.

1. Many clients who experience abuse are hesitant to talk about it and need help to do so. The nurse should ask the client directly about abuse when it is suspected, using a sensitive, empathetic, and compassionate approach. In this way, the client can feel comfortable revealing information about the abuse. Telling the client that it's diffi cult to believe her injuries resulted from a fall is not helpful because it is blameful and puts the client on the defensive. Asking the client what she did to make someone hit her or discussing what she can do the next time blames and alienates the client

A nurse is caring for a client who exhibits pinpoint pupils as well as decreased blood pressure, pulse, respirations, and temperature. These symptoms may be a sign of intoxication with which substance? 1. Opiate 2. Amphetamine 3. Cannabis 4. Alcohol

1. Opiates, such as morphine or heroin, cause these changes. Amphetamines dilate pupils. Cannabis intoxication causes tachycardia, dry mouth, and increased appetite. Alcohol intoxication causes unsteady gait, incoordination, nystagmus, and flushed face.

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 bout the physiologic damage

1. The most effective way to help decrease the client's denial is to point out how alcohol has gotten the client into trouble, using specifi c, 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

112. The client in the early stage of Alzheimer's disease and his adult son attend an appointment at the community mental health center. While conversing with the nurse, the son states, "I'm tired of hearing about how things were 30 years ago. Why does Dad always talk about the past?" The nurse should tell the son: ■ 1. "Your dad lost his short-term memory, but he still has his long-term memory." ■ 2. "You need to be more accepting of your dad's behavior." ■ 3. "I want you to understand your dad's level of anxiety." ■ 4. "Telling your dad that you are tired of hearing about the past will help him stop

1. The son's statements regarding his father's recalling past events is typical for family members of clients in the early stage of Alzheimer's disease, when recent memory is impaired. Telling the son to be more accepting is critical and not an attempt to educate. Understanding the client's level of anxiety is unrelated to the memory loss of Alzheimer's disease. The client cannot stop reminiscing at wil

118. When helping the families of clients with Alzheimer's disease cope with vulgar or sexual behaviors, which of the following suggestions is most helpful? ■ 1. Ignore the behaviors, but try to identify the underlying need for the behaviors. ■ 2. Give feedback on the inappropriateness of the behaviors. ■ 3. Employ anger management strategies. ■ 4. Administer the prescribed risperidone (Risperdal

1. The vulgar or sexual behaviors are commonly expressions of anger or more sensual needs that can be addressed directly. Therefore, the families should be encouraged to ignore the behaviors but attempt to identify their purpose. Then the purpose can be addressed, possibly leading to a decrease in the behaviors. Because of impaired cognitive function, the client is not likely to be able to process the inappropriateness of the behaviors if given feedback. Likewise, anger management strategies would be ineffective because the client would probably be unable to process the inappropriateness of the behaviors. Risperidone (Risperdal) may decrease agitation, but it does not improve social behaviors. C

The expected outcome for using thiamine for a client being treated for an alcohol addiction is to: ■ 1. Prevent the development of Wernicke's encephalopathy. ■ 2. Decrease clients' withdrawal symptoms. ■ 3. Aid clients in regaining their strength sooner. ■ 4. Promote elimination of alcohol from the body faster.

1. Thiamine specifi cally prevents the development of Wernicke's encephalopathy, a reversible amnestic disorder caused by a diet defi cient in thiamine secondary to poor nutritional intake that commonly accompanies chronic alcoholism. It is characterized by nystagmus, ataxia, and mental status changes. Because the client would rather drink alcohol than eat, the client is depleted of vitamins and nutrients. Alcohol also is an irritant that causes a "malabsorption syndrome" in which vitamins and nutrients are not absorbed properly in the gastrointestinal tract. Thiamine is not associated with decreasing withdrawal symptoms, helping clients regain their strength, or promoting elimination of alcohol from the body.

A nurse is caring for a client in a substance abuse clinic. The client tells the nurse he needs more heroin to produce the same effect that he experienced a few weeks ago. How should the nurse describe this condition? 1. Tolerance 2. Dependence 3. Withdrawal delirium 4. Compulsion

1. Tolerance occurs when more drug is required to produce the same effect. Dependence is a physiologic dependence on a substance. Withdrawal delirium occurs when cessation of a substance produces physiologic symptoms. Compulsion refers to an unwanted repetitive act.

The nurse is assessing a 7-year-old boy with Tourette syndrome. Which of the following is a priority for the nurse to assess? ■ 1. Multiple motor and verbal tics. ■ 2. Primarily motor tics. ■ 3. Isolated verbal tics. ■ 4. Alternating simple and complex motor tics.

1. Tourette syndrome is characterized by motor and verbal tics. The disorder begins with simple tics, such as fi nger twitching, and may progress to a complex tic involving movement of the entire arm. There also may be diffi culties with obsessions and compulsions.

120. The husband of a client with Alzheimer's disease that was diagnosed 6 years ago approaches the nurse and says, "I'm so excited that my wife is starting to use donepezil (Aricept) for her illness." The nurse should tell the husband: ■ 1. The medication is effective mostly in the early stages of the illness. ■ 2. The adverse effects of the drug are numerous. ■ 3. The client will attain a functional level of that of 6 years ago. ■ 4. Effectiveness in the terminal phase of the illness is scientifi cally proven.

1. When compared with other similar medications, donepezil (Aricept) has fewer adverse effects. Donepezil is effective primarily in the early stages of the disease. The drug helps to slow the progression of the disease if started in the early stages. After the client has been diagnosed for 6 years, improvement to the level seen 6 years ago is highly unlikely. Data are not available to support the drug's effectiveness for clients in the terminal phase of the disease.

A toddler who has been treated for a foreign body aspiration begins to fuss and cry when the parents attempt to leave the hospital for an hour. The parents will be returning to take the toddler home. As the nurse tries to take the child out of the crib, the child pushes the nurse away. The nurse interprets this behavior as indicating separation anxiety involving which of the following? ■ 1. Protest. ■ 2. Despair. ■ 3. Regression. ■ 4. Detachment.

1. Young children have specifi c reactions to separation and hospitalization. In the protest stage, the toddler physically and verbally attacks anyone who attempts to provide care. Here, the child is fussing and crying and visibly pushes the nurse away. In the despair stage, the toddler becomes withdrawn and obviously depressed (e.g., not ngaging in play activities and sleeping more than usual). Regression is a return to a developmentally earlier phase because of stress or crisis (e.g., a toddler who could feed himself before this event is not doing so now). Denial or detachment occurs if the toddler's stay in the hospital without the parent is prolonged because the toddler settles in to the hospital life and denies the parents' existence (e.g., not reacting when the parents come to visit)

the 2 types of anorexia nervosa

1. restrictive diet and exercise 2, binge eating and purging- binge-eating and misuse of laxatives, diuretics, or enemas

The client is started on buprenorphine with naloxone (Suboxone) sublingual for opiate addiction. Which statements indicate that the client understood the nurse's instructions about the medication? Select all that apply. 1. "The medication can slow or stop my breathing. I should only take what is prescribed.' 2. "I'm taking this non—habit-forming medication to help stop my craving for opiate drugs," 3. if I suddenly stop taking buprenorphine and naloxone, I could experience withdrawal." 4. "I can take the tablet whole or crush it and take it with food to make it more palatable." 5. "This drug is abused: I should not share

1.3.5

What are the principles of Motivational Interviewing?

1.Express empathy. 2. Support Self-efficacy. 3. Roll with resistance. 4. Develop discrepancy.-a lack of compatibility or similarity-• Creates a disconnect between the patient's goals and their continued alchol and other drugs

Which of the following should the nurse expect to assess for a client who is exhibiting late signs of heroin withdrawal? ■ 1. Vomiting and diarrhea. ■ 2. Yawning and diaphoresis. ■ 3. Lacrimation and rhinorrhea. ■ 4. Restlessness and irritability

1.Vomiting and diarrhea are usually late signs of heroin withdrawal, along with muscle spasm, fever, nausea, repetitive sneezing, abdominal cramps, and backache. Early signs of heroin withdrawal include yawning, tearing (lacrimation), rhinorrhea, and sweating. Intermediate signs of heroin withdrawal are fl ushing, piloerection, tachycardia, tremor, restlessness, and irritabilit

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

1.the best way to intervene with a client's minimization or denial of alcohol problems ms is to point out the consequences of the drinking—the

58. A client is experiencing alcohol withdrawal. He wakes up and screams, "There's something crawling under my skin. Help me." In which order, from fi rst to last, should the following nursing actions be done? 1. Remind the client that he is having withdrawal symptoms and that these will be treated. 2. Administer a dose of lorazepam (Ativan) depending on the severity of the withdrawal symptoms. 3. Assess the client for other withdrawal symptoms. 4. Take the client's vital signs 5. Chart the details of the episode on the electronic health record

14325 After the nurse reminds the client about this withdrawal symptom, the nurse should take the client's vital signs and then assess for other symptoms, such as visual and auditory disturbances, tremors, anxiety, nausea and excess perspiration. The elevation of the vital signs also helps to determine the amount of Ativan needed to control the withdrawal symptoms. The nurse should then chart the details of the episode and outcomes of the interventions.

Bulimia Nervosa age onset

15-24 and more people have it

. On discharge after treatment for alcoholism, a client plans to take disulfiram (Antabuse) as prescribed. When teaching the client about this drug, the nurse emphasizes the need to: A. avoid all products containing alcohol. B. adhere to concomitant vitamin B therapy. C. return for monthly blood drug level monitoring. D. limit alcohol consumption to a moderate level.

16. A. avoid all products containing alcohol. **Rationale: To avoid severe adverse effects, the client taking disulfiram must strictly avoid alcohol and all products that contain alcohol. Vitamin B therapy and blood monitoring aren't necessary during disulfiram therapy.

The client is to be discharged from the hospital after a safe, medically supervised withdrawal from alcohol. Which of the following outcomes indicate client readiness for an outpatient alcohol treatment program? Select all that apply. ■ 1. The client states the need to cut down on his alcohol intake. ■ 2. The client verbalizes the damaging effects of alcohol on his body. ■ 3. The client plans to attend Alcoholics Anonymous meetings. ■ 4. The client takes naltrexone (ReVia) daily. ■ 5. The client says he is indestructible.

2, 3, 4. The client who plans to attend Alcoholics Anonymous meetings, verbalizes the damaging effects of alcohol on his body, and takes naltrexone daily may be ready for alcohol rehabilitation. Other key outcomes include admitting that a problem with alcohol exists and realizing the negative effects of alcohol on his life. Stating that he needs to cut down on his alcohol intake and that he is indestructible are signs of denial of an alcohol problem.

The nurse discovers that an adolescent client with anorexia nervosa is taking diet pills rather than complying with the diet. What should the nurse do fi rst? ■ 1. Explain to the client how diet pills can jeopardize health. ■ 2. Listen to the client about fears of losing control of eating while being treated. ■ 3. Talk with the client about how weight loss and emaciation worry the health care providers. ■ 4. Inquire about the client's family's worries concerning the client's physical and emotional health.

2. A client with anorexia nervosa commonly has an extreme fear of not being able to control weight. The nurse should address this fear. Explaining the dangers of diet pills or discussing health care provider or family concerns focuses on the effect of the client's weight loss on other people rather than the client. Unless the client is motivated to stop, the client will likely not be successful

A client diagnosed with bulimia tells the nurse she only eats excessively when upset with her best friend, and then she vomits to avoid gaining a lot of weight. The nurse should next: ■ 1. Schedule daily family therapy sessions. ■ 2. Enroll client in a coping skills group. ■ 3. Work with the client to limit her purging. ■ 4. Have client take lorazepam (Ativan) 1 mg as needed whenever she feels the urge to binge.

2. Because the client eats excessively when upset, the best treatment would be a group to help her learn alternative coping skills. Trying to limit purging without controlling binging would result in weight gain and likely increase the client's purging. Daily family therapy sessions are not realistic. Taking lorazepam whenever she feels she needs to binge may temporarily calm the client, but does not address the cause of the binging and purging and further, will lead to drug dependence with longterm

116. Which of the following is a priority to include in the plan of care for a client with Alzheimer's disease who is experiencing diffi culty processing and completing complex tasks? ■ 1. Repeating the directions until the client follows them. ■ 2. Asking the client to do one step of the task at a time. ■ 3. Demonstrating for the client how to do the task. ■ 4. Maintaining routine and structure for the client.

2. Because the client is experiencing diffi - culty processing and completing complex tasks, the priority is to provide the client with only one step at a time, thereby breaking the task up into simple steps, ones that the client can process. Repeating the directions until the client follows them or demonstrating how to do the task is still too overwhelming to the client because of the multiple steps involved. Although maintaining structure and routine is important, it is unrelated to task completion

The nurse is assessing a client for heroin addiction. Which of the following indicate the client has used heroin? ■ 1. Whites red and bloodshot. ■ 2. Pupils small and constricted. ■ 3. Pupils large and dilated. ■ 4. Drooping eyelids.

2. Heroin causes pinpoint pupils. Marijuana causes the eyes to appear red and bloodshot. Cocaine use causes pupils to dilate. Drooping of the eyelids is not typically associated with the use of any substance.

The nurse is assessing a client for heroin addiction. Which of the following indicate the client has used heroin? ■ 1. Whites red and bloodshot. ■ 2. Pupils small and constricted. ■ 3. Pupils large and dilated. ■ 4. Drooping eyelids.

2. Heroin causes pinpoint pupils. Marijuana causes the eyes to appear red and bloodshot. Cocaine use causes pupils to dilate. Drooping of the eyelids is not typically associated with the use of any substance.

90. A 69-year-old client is admitted and diagnosed with delirium. Later in the day, he tries to get out of the locked unit. He yells, "Unlock this door. I've got to go see my doctor. I just can't miss my monthly Friday appointment." Which of the following responses by the nurse is most appropriate? ■ 1. "Please come away from the door. I'll show you your room." ■ 2. "It's Tuesday and you are in the hospital. I'm Anne, a nurse." ■ 3. "The door is locked to keep you from getting lost." ■ 4. "I want you to come eat your lunch before you go the doctor."

2. Loss of orientation, especially for time and place, is common in delirium. The nurse should orient the client by telling him the time, date, place, and who the client is with. Taking the client to his room and telling him why the door is locked does not address his disorientation. Telling the client to eat before going to the doctor reinforces his disori

96. Which of the following is essential when caring for a client who is experiencing delirium? ■ 1. Controlling behavioral symptoms with lowdose psychotropics. ■ 2. Identifying the underlying causative condition or illness. ■ 3. Manipulating the environment to increase orientation. ■ 4. Decreasing or discontinuing all previously prescribed medications

2. The most critical aspect when caring for the client with delirium is to institute measures to correct the underlying causative condition or illness. Controlling behavioral symptoms with lowdose psychotropics, manipulating the environment, and decreasing or discontinuing all medications may be dangerous to the client's health

115. The family of a client, diagnosed with Alzheimer's disease, wants to keep the client at home. They say that they have the most diffi culty in managing his wandering. The nurse should instruct the family to do which of the following? (Select all that apply). ■ 1. Ask the physician for a sleeping medication. ■ 2. Install motion and sound detectors. ■ 3. Have a relative sit with the client all night. ■ 4. Have the client wear a Medical Alert bracelet. ■ 5. Install door alarms and high door locks.

245

A client is preparing to attend at Gamblers Anonymous meeting for the first time. The prototype used by this group is the 12-step program developed by Alcoholics Anonymous. Number in order of priority how the steps would be addressed. 1) Admitting to oneself and to another human being the exact nature of one's wrongs 2) Acknowledging that one is entirely ready to have his or her defects of character removed 3) Admitting that oneself is powerless over gambling and that one's life has become unmanageable 4) Making an effort to practice the 12-step principles in all affairs, and to carry out this message to other compulsive gamblers 5) Making direct amends wherever possible to all people that have been hurt, expect when to do so would further harm them or others

3) Admitting that oneself is powerless over gambling and that one's life has become unmanageable 1) Admitting to oneself and to another human being the exact nature of one's wrongs 2) Acknowledging that one is entirely ready to have his or her defects of character removed 5) Making direct amends wherever possible to all people that have been hurt, expect when to do so would further harm them or others 4) Making an effort to practice the 12-step principles in all affairs, and to carry out this message to other compulsive gambler

The nurse is talking with a client who was diagnosed with bulimia 3 months ago. The client needs more education about the illness if she makes which of the following comments? Select all that apply. ■ 1. "I know that this illness is chronic and intermittent. I'll always have to control it." ■ 2. "If I start severely restricting my eating, I may be building up to a bingeing episode." ■ 3. "When I'm not bingeing and purging, I can skip that Eating Disorder support group." ■ 4. "I've made a real effort to be more social and involved in activities." ■ 5. "My depression is gone so I don't need my antidepressant any longer."

3, 5. Not attending the support group consistently and not taking the antidepressant may lead to a relapse and the client needs this information. Bulimia is chronic and intermittent and involves cycles of bingeing, purging, and restrictive eating. Increased socialization and activities promote healthy relationships

A client is experiencing agnosia as a result of vascular dementia. She is staring at dinner and utensils without trying to eat. Which intervention should the nurse attempt fi rst? ■ 1. Pick up the fork and feed the client slowly. ■ 2. Say, "It's time for you to start eating your dinner." ■ 3. Hand the fork to the client and say, "Use this fork to eat your green beans." ■ 4. Save the client's dinner until her family comes in to feed her.

3. Agnosia is the lack of recognition of objects and their purpose. The nurse should inform the client about the fork and what to do with it. Feeding the client does not address the agnosia or give the client specifi c directions. It should only be attempted if identifying the fork and explaining what to do with it is ineffective. Waiting for the family to care for the client is not appropriate unless identifying the fork and explaining or feeding the client are not successful.

high school student taking atomoxetine (Strattera) for ADHD disorder visits the school nurse's office and confides "I am so depressed. The world would be better off without me." Which actions would the nurse take for this client. 1. Tell the client to stop taking atomoxetine immediately and not to take it until checking with the provider. 2. Assure the client that these are normal symptoms because the drug may 3 or 4 weeks to work. 3. Alert the family or caregiver that immediate attention and treatment are needed for these symptoms. 4. Have the client increase intake of caffeine by consuming cola products, coffee, or tea to counteract the depressive effec

3. Alert the family or caregiver that immediate attention and treatment are needed for these symptoms.

121. The physician orders risperidone (Risperdal) for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which of the following behaviors? ■ 1. Sleep disturbances. ■ 2. Concomitant depression. ■ 3. Agitation and assaultiveness. 4. Confusion and withdrawal

3. Antipsychotics are most effective with agitation and assaultiveness. Antipsychotics have little effect on sleep disturbances, concomitant depression, or confusion and withdrawal.

A client newly diagnosed with bulimia is attending the nurse-led group at the mental health center. She tells the group that she came only because her husband said he would divorce her if she didn't get help. Which of the following responses by the nurse is appropriate? ■ 1. "You sound angry with your husband. Is that correct?" ■ 2. "You will fi nd that you like coming to group. These people are a lot of fun." ■ 3. "Tell me more about why you are here and how you feel about that." ■ 4. "Tell me something about what has caused you to be bulimic.

3. Encouraging the client to talk about why she is here and her feelings may reveal more information about what led her to come to the group and what led to her diagnosis. It also provides the nurse with valuable information needed to develop an appropriate plan of care. The comment that the client sounds angry presumes what the client is feeling and focuses the talk on her husband. The focus should be on the client, not the husband. Telling the client that she will like coming to group imposes the nurse's view onto the client. The statement also focuses on having fun in the group instead of stressing the therapeutic value. Having the client tell the nurse something about the cause of her bulimia ignores the client's original statement. In addition, it requires the client to have insight into the cause of her disease, which may not be possible at this point. Also, it may be too early in the relationship to discuss this disorder

Which of the following is a realistic shortterm goal to be accomplished in 2 to 3 days for a client with delirium? ■ 1. Explain the experience of having delirium. ■ 2. Resume a normal sleep-wake cycle. ■ 3. Regain orientation to time and place. ■ 4. Establish normal bowel and bladder function.

3. In approximately 2 to 3 days, the client should be able to regain orientation and thus become oriented to time and place. Being able to explain the experience of having delirium is something that the client is expected to achieve later in the course of the illness, but ultimately before discharge. Resuming a normal sleep-wake cycle and establishing normal bowel and bladder function probably will take longer, depending on how long it takes to resolve the underlying condition.

A hospitalized adolescent diagnosed with anorexia nervosa refuses to comply with her daily before-breakfast weigh-in. She states that she just drank a glass of water, which she feels will unfairly increase her weight. What is the nurse's best response to the client? 1. "You are here to gain weight so that will work in your favor." ■ 2. "Don't drink or eat for 2 hours and then I'll weigh you." ■ 3. "You must weigh in every day at this time. Please step on the scale." ■ 4. "If you don't get on the scale, I will be forced to call your doctor."

3. In responding to the client, the nurse must be nonjudgmental and matter of fact. Telling her that weight gain is in her favor ignores the client's extreme fear of gaining weight. Putting off the weigh-in for 2 hours allows the client to manipulate the nurse and interferes with the need to weigh the client at the same time each day. Threatening to call the doctor is not likely to build rapport or a working relationship with the client.

40. Which of the following assessments provides the best information about the client's physiologic response and the effectiveness of the medication prescribed specifi cally for alcohol withdrawal? ■ 1. Nutritional status. ■ 2. Evidence of tremors. ■ 3. Vital signs. ■ 4. Sleep pattern

3. Monitoring vital signs provides the best information about the client's overall physiologic status during alcohol withdrawal and the physiologic response to the medication used. Vital signs refl ect the degree of central nervous system irritability and indicate the effectiveness of the medication in easing withdrawal symptoms. Although assessment of nutritional status and sleep pattern and assessment for evidence of tremors are important, they provide only indirect information about single aspects of the client's physiologic status

94. When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate? ■ 1. Cancer of any kind. ■ 2. Impaired hearing. ■ 3. Prescription drug intoxication. ■ 4. Heart failure.

3. Polypharmacy is much more common in the elderly. Drug interactions increase the incidence of intoxication from prescribed medications, especially with combinations of analgesics, digoxin, diuretics, and anticholinergics. With drug intoxication, the onset of the delirium typically is quick. Although cancer, impaired hearing, and heart failure could lead to delirium in the elderly, the onset would be more gradual.

An outpatient client who has a history of paranoid schizophrenia and chronic alcohol dependency has been taking risperidone (Risperdal) for several months. She reports that she stopped drinking 4 days ago. The client is very frightened by the tactile hallucinations of bugs crawling under her skin. Which of the following factors should the nurse incorporate into the plan of care when explaining the tactile hallucinations? ■ 1. Alcohol intoxication. ■ 2. Ineffectiveness of risperidone. ■ 3. Alcohol withdrawal. ■ 4. Interaction of alcohol and risperidone.

3. Tactile hallucinations are more common in alcohol withdrawal than in schizophrenia. Therefore, the nurse should explain that these hallucinations are the result of withdrawal from alcohol. Because the client stopped drinking 4 days ago, the client is not intoxicated. Risperidone has little effect on symptoms of alcohol withdrawal. It is prescribed for symptoms of schizophrenia. Alcohol and risperidone have an additive effect, not one of causing hallucinations.

59. Which of the following measures should the nurse include in the plan of care for a client with alcohol withdrawal delirium? ■ 1. Using restraints continuously. ■ 2. Touching the client before saying anything. ■ 3. Remaining with the client when she is confused or disoriented. ■ 4. Informing the client about alcohol treatment programs

3. The client with alcohol withdrawal delirium should not be left unattended when confused, disoriented, or hallucinating. Injury or unintentional suicide is a possibility when the client attempts to get away from hallucinations. Restraints are used only when the client loses control and is a danger to herself or others, to protect the client from injury or harm. Touching the client before saying anything is an additional stimulus that would most likely add to the client's agitation. Informing the client about the alcohol treatment program while the client is delirious is inappropriate and shows poor nursing judgment. The client should be given information about alcohol treatment when the withdrawal symptoms are lessening and the client can comprehend the information

117. The client with Alzheimer's disease may have delusions about being harmed by staff and others. When the client expresses fear of being killed by staff, which of the following responses is most appropriate? ■ 1. "What makes you think we want to kill you?" ■ 2. "We like you too much to want to kill you." ■ 3. "You are in the hospital. We are nurses trying to help you." ■ 4. "Oh, don't be so silly. No one wants to kill you here."

3. The nurse needs to present reality without arguing with the delusions. Therefore, stating that the client is in the hospital and the nurses are trying to help is most appropriate. The client doesn't recognize the delusion or why it exists. Telling the client that the staff likes him too much to want to kill him is inappropriate because the client believes the delusions and doesn't know that they are false beliefs. It also restates the word, kill, which may reinforce the client's delusions. Telling the client not to be silly is condescending and disparaging and therefore inappropriate.

A 15-year-old boy being successfully treated for Tourette's syndrome tells the nurse, "I'm not going to take this medication anymore. Anyone who is really my friend will accept me as I am tics and all!" The nurse should tell the client? ■ 1. "You and your family came to the clinic for treatment, so you can terminate it whenever you wish." ■ 2. "Won't your lack of medication cause more tics and make you be less attractive to girls?" ■ 3. "Let's talk about what brought you into treatment and why you now want to stop taking medication." ■ 4. "I think that is a very unwise decision, but you're entitled to do whatever you wis

3. When an adolescent wants to stop treatment with medication it represents a desire for more control over his/her life as well as a wish to be free of the disorder with which they have been diagnosed. If the caregiver merely acknowledges the client's right to stop treatment or warns of consequences if the client stops medication, he or she abdicates the adult role of healthcare advisor. Before any action is taken, the nurse should explore the client's reasoning to see if anything in the medication regimen could be changed to make it more palatable for the client. The client also needs to know if his current objections cannot be overcome, he can return later to restart his medication.

Which of the following should lead the nurse to suspect that a client is addicted to heroin? ■ 1. Hilarity. ■ 2. Aggression. ■ 3. Labile mood. ■ 4. Hypoactivity

3.The client who is addicted to heroin is most likely to exhibit hypoactivity. Initially, the client feels euphoric. This is followed by drowsiness, hypoactivity, anorexia, and a decreased sex drive. Hilarity, aggression, and a labile mood usually are not associated with heroin addiction

A client has been admitted to the emergency department with alcohol withdrawal delirium. The nurse is assessing the client for signs of withdrawal. At 9 a.m. on 10/25, the nurse notes that the client is confused. His vital signs are T = 99° F, P = 50, R = 10, and BP = 100/60. The nurse compares these fi ndings to the nurses' progress notes from admission 24 hours ago (see below). What should the nurse do fi rst? ■ 1. Contact the physician. ■ 2. Increase the rate of the I.V. infusion. ■ 3. Attempt to arouse the client. ■ 4. Administer magnesium sulfate.

31. 1. The nurse should fi rst contact the physician. The client's vital signs and level of consciousness are deteriorating, indicating complications of withdrawal, which can be life-threatening. Increasing the rate of the infusion may cause fl uid overload and has not been ordered by the physician. Arousing the client will not address the underlying problems. Magnesium sulfate is used to treat seizures precipitated by alcohol withdrawal, but the client is not demonstrating signs of actual or impending seizures

An unconscious client in the emergency department is given I.V. naloxone (Narcan) due to an overdose of heroin. Which of the following would indicate a therapeutic response to the Narcan? Select all that apply. ■ 1. Decreased pulse rate. ■ 2. Warm skin. ■ 3. Dilated pupils. ■ 4. Increased respirations. ■ 5. Consciousness

4, 5. Naloxone is an opioid antagonist used to treat an opioid overdose. Within a few minutes, the client should have an increase of respirations to near normal and become conscious. With a heroin overdose, the pulse is not signifi cantly affected, the skin becomes warm and wet and the pupils are dilated. With naloxone the skin would return to a normal temperature and become dry. The pupils also would react normally and the pulse would not be decreased.

When teaching a group of adolescents about anorexia nervosa, the nurse should describe this disorder as being characterized by which of the following? ■ 1. Excessive fear of becoming obese, near- normal weight, and a self-critical body image. ■ 2. Obsession with the weight of others, chronic dieting, and an altered body image. ■ 3. Extreme concern about dieting, calorie-counting, and an unrealistic body image. ■ 4. Intense fear of becoming obese, emaciation, and a disturbed body image.

4. An intense fear of becoming obese, emaciation, and a disturbed body image all are considered to be characteristic of anorexia nervosa. Near-normal weight is not associated with anorexia. The weight of others is not a primary factor. Concern about dieting is not strong enough language to describe the control of food intake in the individual with anorexia nervosa.

Wernicke's encephalopathy. When developing a teaching plan for the client and his family, the nurse should stress the importance of including which vitamin in his diet? 1. Niacin 2. Riboflavin 3. Ascorbic acid 4. Thiamine

4. B1 Wernicke's encephalopathy is a neurologic disorder seen in a client with chronic alcohol abuse that results from thiamine deficiency. The client should be encouraged to eat a diet rich in thiamine. Niacin, ribo fla vin, and ascorbic acid deficiencies aren't implicated in Wernicke's encephalopathy.

123. When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the following suggestions is most relevant? ■ 1. Allow the client to go to bed four to fi ve times during the day. ■ 2. Test the cognitive functioning of the client several times a day. ■ 3. Provide reality orientation even if the memory loss is severe. ■ 4. Maintain consistency in environment, routine, and caregivers.

4. Change increases stress. Therefore, the most important and relevant suggestion is to maintain consistency in the client's environment, routine, and caregivers. Although rest periods are important, going to bed interferes with the sleepwake cycle. Rest in a recliner chair is more useful. Testing cognitive functioning and reality orientation are not likely to be successful and may increase stress if memory loss is severe.

A client is to be discharged from an alcohol rehabilitation program. Which of the following should the nurse emphasize in the discharge plan as a priority? ■ 1. Supportive friends. ■ 2. A list of goals. ■ 3. Family forgiveness. ■ 4. Follow-up care

4. Follow-up care is essential to prevent relapse. Recovery has just begun when the treatment program ends. The fi rst few months after program completion can be diffi cult and dangerous for the chemically dependent client. The nurse is responsible for discharge plans that include arrangements for counseling, self-help group meetings, and other forms of aftercare. Supportive friends, a list of goals, and family forgiveness may be important and help

67. A successful real estate agent brought to the clinic after being arrested for harassing and stalking his ex-wife denies any other symptoms or problems except anger about being arrested. The ex-wife reports to the police, "He is fi ne except for this irrational belief that we will remarry." When collaborating with the health care provider about a plan of care, which of the following will be most effective for the client at this time? ■ 1. An order for olanzapine (Zyprexa) 10 mg daily. ■ 2. A joint session with the client and his ex-wife. ■ 3. An order for fl uoxetine (Prozac) 20 mg every morning. ■ 4. Referral to an outpatient therapist

4. Follow-up counseling is appropriate because of the client's anger and inappropriate behaviors. The goal is to help the client deal with the end of his marriage. A joint session might have been useful before the divorce and arrest, but not after. The client is exhibiting no signs or symptoms of schizophrenia or psychosis, so olanzapine is not indicated. The client is not exhibiting signs of depression, so fl uoxetine is not indicated.

The client tells the nurse at the outpatient clinic that she doesn't need to attend groups because she's "not a regular like these other people here." The nurse should respond to the client by saying: ■ 1. "Because you're not a regular client, sit in the hall when the others are in group." ■ 2. "Your family wants you to attend, and they will be very disappointed if you don't." ■ 3. "I'll have to mark you absent from the clinic today and speak to the doctor about it." ■ 4. "You say you're not a regular here, but you're experiencing what others are experiencing."

4. The best response is, "You say you're not a regular here, but you're experiencing what others are experiencing." This statement helps the client to identify factors that precipitate denial by helping her to confront that which inhibits compliance. Denial is used to help a client feel better and more secure when a situation provokes a high level of anxiety and is threatening to the client. The statement, "Because you're not a regular client, sit in the hall when the others are in group," agrees with and promotes denial in the client and interferes with treatment. The statement, "Your family wants you to attend and they will be disappointed if you don't," causes the client to feel guilty and decreases her self-esteem. The statement, "I'll have to mark you absent from the clinic today and speak to the doctor about it," is punitive and threatening to the client, subsequently decreasing her self-esteem

A 6-year-old female is brought to the school nurse for refusal to sit in class. She denies feeling sick but insists that her mother be called so she can go home. She is pacing and chewing on a fi ngernail. This has occurred daily since school began 4 weeks ago. She tells the nurse that she is afraid something bad is going to happen to her mother. The nurse should continue to gather data that indicates which of the following? ■ 1. Obsessive-compulsive disorder. ■ 2. Major depression. ■ 3. Attention defi cit hyperactivity disorder. ■ 4. Separation anxiety disorder

4. The child's refusal to sit in class, insistence on calling her mother when she isn't ill, fear that something bad is going to happen to her mother, and physical appearance of anxiety best fi t separation anxiety disorder. Children with separation anxiety disorder display these types of behaviors for a month or longer. Obsessive-compulsive disorder would be manifested by ritualistic, repetitive behaviors that are excessive and interfere with normal activities. Major depression in children is evidenced by sadness or acting-out behaviors. Attention defi cit hyperactivity disorder is manifested by failure to complete tasks, an inability to pay attention during class, and easy distractibility.

When teaching a client who is to receive methadone therapy for opioid addiction, the nurse should instruct the client that methadone is useful primarily for which of the following reasons? ■ 1. It is not an addictive substance. ■ 2. A maintenance dose is taken twice a day. ■ 3. The client will no longer be addicted to opioids. ■ 4. The client may work and live normally

4. The client takes methadone primarily to be able to work, live normally, and function productively without the mental and physical deterioration caused by opioid addiction. Methadone lessens physiologic dependence on opioids and is used to prevent withdrawal symptoms. Methadone, a substance similar to morphine, is an addictive substance; the client is still considered addicted to opioids. Because methadone has a long half-life of 15 to 30 hours, it can be taken once a day on an outpatient basis.

An intoxicated client is admitted to the hospital for alcohol withdrawal. Which of the following should the nurse do to help the client become sober? ■ 1. Give the client black coffee to drink. ■ 2. Walk the client around the unit. ■ 3. Have the client take a cold shower. ■ 4. Provide the client with a quiet room to sleep in

4. The nurse should provide the client with a quiet room to sleep in. Alcohol is destroyed and oxidized in the body at a slow, steady rate. The rate of alcohol metabolism is not infl uenced by drinking black coffee, walking around the unit, or taking a cold shower. Therefore, it is best to have the client sleep off the effects of the alcohol

119. The nurse determines that the son of a client with Alzheimer's disease needs further education about the disease when he makes which of the following statements? ■ 1. "I didn't realize the deterioration would be so incapacitating." ■ 2. "The Alzheimer's support group has so much good information." ■ 3. "I get tired of the same old stories, but I know it's important for Dad." ■ 4. "I woke up this morning expecting that my old Dad would be back."

444444444444444

Anorexia Nervosa Diagnostic Criteria

: Diagnosed when a restriction of intake has led to significantly low body weight. the BMI is used as a measure of severity.

A client with Buerger's disease has established a goal to stop smoking. Which medication would be the most helpful in attaining this goal? ■ 1. Zyban (Bupropion). ■ 2. Nicotine (Nicotrol). ■ 3. Nitroglycerin (Tridil). ■ 4. Ibuprofen (Advil)

A client with Buerger's disease has established a goal to stop smoking. Which medication would be the most helpful in attaining this goal? ■ 1. Zyban (Bupropion). ■ 2. Nicotine (Nicotrol). ■ 3. Nitroglycerin (Tridil). ■ 4. Ibuprofen (Advil)

Tommy says to his friend, "I can't even talk to my Daddy until after he has read his newspaper." This is an example of which of the following? A. Rigid boundary B. A boundary violation C. Enmeshed boundary. D. Too flexible boundary

A. Rigid boundary is the correct answer. The father has set rigid boundaries to keep others out of his personal space.

The school nurse asseses Brook, a child newly diagnosed with attention deficit hyperactivity disorder (ADHD). Which of the following symptoms are characteristic of the disorder? Select all that apply. A Constant fidgeting and squirming B Excessive fatigue and somatic complaints C Difficulty paying attention to details D Easily distracted E Running away F Talking constantly, even when inappropriate

ACDF

Impulsiveness sign of

ADHD

Atomoxetine (Strattera) RX FOR

ADHD AND THIS MED LESS SLEEP PROBLEMS

The nurse is caring for a patient with attention deficit hyperactivity disorder (ADHD). Which medication order should the nurse question? 1. Strattera (atomoxetine) 2. Lithobid (lithium) 3. Wellbutrin (bupropion) 4. Concerta (methylphenidate

ANS: 2 Rationale: Patients with attention deficit hyperactivity disorder (ADHD) may be prescribed stimulants (e.g., methylphenidate), nonstimulants (e.g., atomoxetine), tricyclic antidepressants (e.g., desipramine), or atypical antidepressants (e.g., bupropion). Lithium is indicated for bipolar disorder; therefore, the nurse should question this medication order. Nursing Process: Implementation Cognitive Level: Analysis NCLEX Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

A kindergartener is disruptive in class. This child is unable to sit for expected lengths of time, inattentive to the teacher, screams while the teacher is talking, and is aggressive toward other children. The nurse plans interventions designed to: a. promote integration of self-concept. b. provide inpatient treatment for the child. c. reduce loneliness and increase self-esteem. d. improve language and communication skills.

ANS: C Because of their disruptive behaviors, children with ADHD often receive negative feedback from parents, teachers, and peers, leading to self-esteem disturbance. These behaviors also cause peers to avoid the child with ADHD, leaving the child with ADHD vulnerable to loneliness. The child does not need inpatient treatment at this time. The incorrect options might or might not be relevant.

A desired outcome for a 12-year-old diagnosed with attention deficit hyperactivity disorder (ADHD) is to improve relationships with other children. Which treatment modality should the nurse suggest for the plan of care? a. Reality therapy b. Simple restitution c. Social skills group d. Insight-oriented group therapy

ANS: C Social skills training teaches the child to recognize the impact of his or her behavior on others. It uses instruction, role-playing, and positive reinforcement to enhance social outcomes. The other therapies would have lesser or no impact on peer relationships.

A client's wife has been making excuses for her alcoholic husband's work absences. In family therapy, she states, "His problems at work are my fault." Which is the appropriate nursing response? A. "Why do you assume responsibility for his behaviors?" B. "Codependency is a typical behavior of spouses of alcoholics." C. "Your husband needs to deal with the consequences of his drinking." D. "Do you understand what the term 'enabler' means?"

ANS: C The appropriate nursing response is to use confrontation with caring. The nurse should understand that the client's wife may be in denial and enabling the husband's behavior. Partners of clients with substance abuse must come to realize that the only behavior they can control is their own.

What is the nurse's priority focused assessment for side effects in a child taking methylphenidate (Ritalin) for attention deficit hyperactivity disorder (ADHD)? a. Dystonia, akinesia, and extrapyramidal symptoms b. Bradycardia and hypotensive episodes c. Sleep disturbances and weight loss d. Neuroleptic malignant syndrome

ANS: C The most common side effects are gastrointestinal disturbances, reduced appetite, weight loss, urinary retention, dizziness, fatigue, and insomnia. Weight loss has the potential to interfere with the child's growth and development. The distracters relate to side effects of conventional antipsychotic medicatio

On the first day of a client's alcohol detoxification, which nursing intervention should take priority? A. Strongly encourage the client to attend 90 Alcoholics Anonymous meetings in 90 days. B. Educate the client about the biopsychosocial consequences of alcohol abuse. C. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. D. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.

ANS: C The priority nursing intervention for this client should be to administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. Chlordiazepoxide (Librium) is a benzodiazepine and is often used for substitution therapy in alcohol withdrawal. Substitution therapy may be required to reduce life-threatening effects of the rebound stimulation of the central nervous system that occurs during withdrawal.

The parent of a 6-year-old says, "My child is in constant motion and talks all the time. My child isn't interested in toys but is out of bed every morning before me." The child's behavior is most consistent with diagnostic criteria for: a. communication disorder. b. stereotypic movement disorder. c. intellectual development disorder. d. attention deficit hyperactivity disorder.

ANS: D Excessive motion, distractibility, and excessive talkativeness are seen in attention deficit hyperactivity disorder (ADHD). The behaviors presented in the scenario do not suggest intellectual development, stereotypic, or communication disorder.

An adolescent bodybuilder has been taking anabolic steroids to increase his weight and the size and definition of his muscles. Psychological effects of anabolic steroids include: . Confusion and self-doubt Aggression and uncontrolled rage Elation and excitability Decreased inhibitions and humor

Aggression and uncontrolled rage

family interactions can be problematic (enmeshment, overprotectiveness, rigidity)

Anorexia nervosa Family

The client is diagnosed with Wernicke-Korsakoff syndrome as a result of chronic alcoholism. Which symptoms would the nurse assess? A. Insomnia and anxiety B. Visual or auditory hallucinations C. Extreme tremors and agitation D. Ataxia and confabulation

Answer: (D) Ataxia or lack of coordination and confabulation, making up elaborate stories to explain lapses in memory, are both symptoms of Wernicke-Korskoff syndrome. Answers 2 and 3 are symptoms of delirium tremen

. A nurse is caring for a client who was accused of voyeurism by his neighbors. Which term most appropriately describes such behavior? 1. Paraphilia 2. Depersonalization disorder 3. Dissociative fugue 4. Gender identity disorde

Answer: 1. Paraphilia is a general diagnosis that encompasses such disorders as exhibitionism, fetishism, pedophilia, and voyeurism. Depersonalization disorder is characterized by a feeling of detachment or estrangement from one's self. Dissociative fugue is characterized y sudden, unexpected travel away from home, accompanied by an inability to recall one's past. Gender identity disorder is a separate diagnostic category and isn't related to paraphilias

A client with a long history of alcoholism recently was diagnosed with Wernicke-Korsakoff syndrome. Which symptom should the nurse expect to assess? a. A sudden onset of muscle pain with elevations of creatinine phosphokinase b. Signs and symptoms of congestive heart failure c. Loss of short-term and long-term memory and the use of confabulation d. Inflammation of the stomach and gastroesophageal reflux disorder

Answer: C: Loss of short-term and long-term memory and the use of confabulation are symptoms of Wernicke-Korsakoff syndrome. The treatment is alcohol abstinence and thiamine replacement.

For a nurse to develop a therapeutic attitude toward the treatment of alcohol, tobacco, and other drug (ATOD) problems in the community, the nurse must realize drug addiction can be successfully treated, anyone may develop drug dependence, and: A. any drug can be abused. B. illegal drugs are the category of abused drugs. C. prescription drugs rarely cause dependence. D. over-the-counter (OTC) drugs are "good drugs."

Answer: any drug can be abused. Rationale: A health care approach to ATOD problems is the harm reduction model. This is a new public health model that nurses can use to treat individuals, families, and communities. To develop a therapeutic attitude, the nurse must realize that any drug can be abused, anyone may develop drug dependence, and drug addiction can be successfully treated.

A client with a long history of heroin abuse is showing signs of cognitive deficits. Which drug would the nurse recognize as appropriate in assisting with this client's recovery? a. Acamprosate calcium (Campral) b. Buprenorphine/naloxone (Suboxone) c. Disulfiram (Antabuse) d. Haloperidol (Haldol)

Answer: b: Suboxone is approved by the FDA for opioid addiction.

The nurse is caring for a client with detoxification from alcohol. Which medication is used in the treatment of alcohol withdrawal? Antabuse (disulfiram) Romazicon (flumazenil) Dolophine (methodone) Ativan (lorazepam)

Ativan (lorazepam)

Velma told Betty a secret that Mary told her. This is an example of which of the following? A. Too flexible boundary. B. A boundary violation. C. Rigid boundary. D. Enmeshed boundary

B. A boundary violation is the correct answer because Velma told Betty something that Mary shared with her in confidence. Other examples of boundary violations are invading someone's personal space, opening their mail, reading their diary, unwanted touching, even smoking in non-smoking public areas. Telling someone they "should" believe, feel, decide, choose or think in a certain way is another example of a boundary violation.

wins Jan and Jean still dress alike even though they are grown and married. This is an example of which of the following? A. Rigid boundary B. Enmeshed boundary C. A boundary violation D. Boundary pliancy

B. Enmeshed boundary is the correct answer because when two people's boundaries are so blended together that neither can be sure where one stops and the other begins. They may be unable to differentiate his or her feelings, wants, and needs from the other person's. This does not only apply to twins. Boundary pliancy refers to a boundary being either rigid, flexible or enmeshed. A boundary violation would be an unwanted intrusion of anothers personal or psychological space. D. Boundary pliancy

Intoxication as determined by blood alcohol level

BAL; 0.10% or greater is considered intoxication.)

The simplest biological measure to obtain is blood alcohol content

Breathalyzer

boundary problems seen in

Bulimia Nervosa

Which of the following is a treatment used with bulimia nervosa? 0A: Cognitive- behavioral therapy 0B: Antipsychotic medication 0C: Fasting 0D: Intravenous therapy

Cognitive-behavioral therapy is a type of therapy that has been successful with patient with bulimia nervosa (option A). Antipsychotic medication, fasting and intravenous therapy are not treatment modalities for bulimia nervosa (options, B, C, D).

used most frequently to treat or prevent alcohol withdrawal

Diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium)

heroine overdose

Dilated pupils • Respiratory depression leading to respiratory arrest • Circulatory depression leading to cardiac arrest • Unconsciousness leading to coma • Death

Nurse Fey is aware that the drug of choice for treating Tourette syndrome?

Haloperidol is the drug of choice for treating Tourette syndrome. Prozac, Luvox, and Paxil are antidepressants and aren't used to treat Tourette syndrome

what is motivational therapy used for

Helps patient recognize a problem and develop change strategies

98. Which of the following should the nurse expect to include as a priority in the plan of care for a client with delirium based on the nurse's understanding about the disturbances in orientation associated with this disorder? ■ 1. Identifying self and making sure that the nurse has the client's attention. ■ 2. Eliminating the client's napping in the daytime as much as possible. ■ 3. Engaging the client in reminiscing with relatives or visitors. ■ 4. Avoiding arguing with a suspicious client about his perceptions of reality.

Identifying oneself and making sure that the nurse has the client's attention addresses the diffi culties with focusing, orientation, and maintaining attention. Eliminating daytime napping is unrealistic until the cause of the delirium is determined and the client's ability to focus and maintain attention improves. Engaging the client in reminiscing and

A 20-year-old client is admitted with bone marrow depression. He tells the nurse he's been using drugs since age 13. Which drug should the nurse anticipate finding in this client's history? 1. Amphetamines 2. Cocaine 3. Inhalants 4. Marijuana

Inhalants cause severe bone marrow depression. Marijuana, cocaine, and amphetamines don't cause bone marrow depression. CN: Physiological integrity; crvs: Pharmacological and parenteral therapies

Naloxone or narcan

It can treat narcotic overdose in an emergency situation.

Bulimia Nervosa def

It involves eating a large amount of food within a discrete period of time (e.g., 2 hrs) and engaging in recurrent episodes of binge-eating and compensatory purging .

A client develops tremors while withdrawing from alcohol. Which medication is routinely administered to lessen physiological effects of alcohol withdrawal? Dolophine (methodone) Klonopin (clonazepam) Narcan (Naloxone) Antabuse (disulfiram)

Klonopin (clonazepam)

Wernicke's encephalopathy may evolve into

Korsakoff Amnestic Syndrome

o treat heroin addiction

Levo-alpha-acetylmethadol

major problems associated with use of inhalants

Long term use can lead to hepatic and renal failure, blood dyscrasias, damage to the lungs; CNS damage (e.g. OBS, peripheral neuropathies, cerebral and optic atrophy, parkinsonism

• Key predictor of whether individuals will change their substance abuse behavior

MOTIVATION

medication treatment to prevent withdrawal symptoms for drugs such as heroin, cocaine and morphine

Methadone

Methadone is a

Methadone just like heroine

is a method of therapeutic intervention that seeks to elicit self-motivational statements from 10 patients, supports behavioral change, and creates a disconnect between the patient's goals and their continued alcohol and other drug use

Motivational interviewing

priority interventions for patients with substance-related disorders.

Motivational approaches

for opiod you must make sure what when using Naltrexone

Must make certain patient is opioid free before administering naltrexone. Always give naloxone challenge test before using, except in patients showing clinical signs of opioid withdrawal. opioid free for 7 to 10 d

DRUGS FOR AUTISM

NONE BUT isperidone, aripiprazole) are approved for the tx of irritability associated with autism

Which nursing diagnosis is universally applicable for children diagnosed with autism spectrum disorders? a. Impaired social interaction related to difficulty relating to others b. Chronic low self-esteem related to excessive negative feedback c. Deficient fluid volume related to abnormal eating habits d. Anxiety related to nightmares and repetitive activities

NS: A Children diagnosed with autism spectrum disorders display profoundly disturbed social relatedness. They seem aloof and indifferent to others, often preferring inanimate objects to human interaction. Language is often delayed and deviant, further complicating relationship issues. The other nursing diagnoses might not be appropriate in all cases.

Which behavior indicates that the treatment plan for a child diagnosed with an autism spectrum disorder was effective? The child: a. plays with one toy for 30 minutes. b. repeats words spoken by a parent. c. holds the parent's hand while walking. d. spins around and claps hands while walking.

NS: C Holding the hand of another person suggests relatedness. Usually, a child with an autism spectrum disorder would resist holding someone's hand and stand or walk alone, perhaps flapping arms or moving in a stereotyped pattern. The incorrect options reflect behaviors that are consistent with autism spectrum disorders.

A nurse assesses a 3-year-old diagnosed with an autism spectrum disorder. Which finding is most associated with the child's disorder? The child: a. has occasional toileting accidents. b. is unable to read children's books. c. cries when separated from a parent. d. continuously rocks in place for 30 minutes.

NS: D Autism spectrum disorder involves distortions in development of social skills and language that include perception, motor movement, attention, and reality testing. Body rocking for extended periods suggests autism spectrum disorder. The distracters are expected findings for a 3-year-old.

When a 5-year-old diagnosed with attention deficit hyperactivity disorder (ADHD) bounces out of a chair and runs over and slaps another child, what is the nurse's best action? a. Instruct the parents to take the aggressive child home. b. Direct the aggressive child to stop immediately. c. Call for emergency assistance from other staff. d. Take the aggressive child to another room.

NS: D The nurse should manage the milieu with structure and limit setting. Removing the aggressive child to another room is an appropriate consequence for the aggressiveness. Directing the child to stop will not be effective. This is not an emergency. Intervention is needed rather than sending the child hom

why must you keep watching pt when giving Narcan

Narcan only lasts 30-90 minutes WATCH patient for repeat overdose symptoms. (Opoids can stay in the system much longer than Narcan) Stay with these patients or get a sitter.

Body Dissatisfaction

Occurs when the body becomes overvalued as a way of determining one's worth. ● the individual begins to compare their body with that of others (such as those of celebrities) ● strongly related to low self-esteem ● may adolescents attempt to overcome this through dieting and overexercising

8. Which type of hallucinations are most often associated with dementia?

Progressive cognitive decline with visual hallucination, rapid eye movement sleep disorder, and spontaneous parkinsonism characterizes dementia with Lewy bodies, a major neurocognitive disorder.

Describe the nursing care for a client with Alzheimer's disease

Provide a safe, consistent environment. (Do not make changes, if possible. Change increases anxiety and confusion.) Stick to routines. If client wanders, make sure he or she has a name tag. Provide assistance as needed with ADLs. Make sure bathroom is clearly labeled

is the primary cause of death among clients who abuse opioid

Respiratory depression

Rigidity

Rigidity refers to families that are heavily committed to maintaining the status quo and so find change difficult. Conflict is avoided, where a strong ethical code or religious orientation is usually the rationale

seperation anxiety is treated with

SSRI o Child & parent psychoeducation o School consultation o Cognitive-behavioral therapy

Frotteurism

Sexually arousing urges, fantasies, and behaviors occur when touching or rubbing one's genitals against the breasts, genitals, or thighs of a nonconsenting person. This paraphilia usually begins in early adolescence or young adulthood and diminishes with age.

Which of the following statements, when made by a client with anorexia nervosa, would indicate body image distortion instead of body image dissatisfaction? a. I don't like how my body looks b. I wish I looked like my sister c. I'm sad I can't wear halter tops d. I am so overweight

Statement D is the only statement that reflects a distorted image of the body. Clients with anorexia nervosa look in the mirror and see someone a lot heavier than they really are. They cannot see that they are too thin.

• Treatment of people with opioid addiction with a daily stabilized dose of methadone

T because • Detoxification accomplished o Set the beginning methadone dose o Slowly reduce over the next 21 days

Cocaine overdose

Tachycardia • Pupillary dilatation • Increased BP • Cardiac arrhythmias • Perspiration, chills • Nausea, vomiting

Varenicline (Chantix) is prescribed for a middle-aged client for smoking cessation. What is a priority nursing action for this client?

Tell the client that nausea and vomiting are likely. Rationale:Nausea and vomiting are likely with this drug. Orthostatic hypotension and hyperthermia are not a concern with this drug. Avoidance of sunlight is not necessary while on this medication.

A patient that police brought into the emergency room today for alcohol intoxication for the third time in the last month has the following lab results. Which one would signal that this patient requires immediate intervention? Sodium: 130 mEq/L WBC: 3.5 x10^9/mcL Potassium: 2.3 mEq/dl Albumin: 3.2 g/dL Blood Alcohol Level: 350 mg/dL

The correct answer is "3" because a low potassium is the most life-threatening imbalance listed. The rest are all abnormal, but not as significant. The biggest distractor is "5" because of the high level, but the question tells you that the patient is there for repeated alcohol abuse, and therefore will have built a tolerance to alcohol.

Night Eating Syndrome

The individual eats after awakening from sleep or consumes an excessive amount of food after the evening meal.

Police bring a client to the emergency department after she threatens to kill her ex-husband. She states emphatically, "The police should bring him in, not me. He's paranoid about my dating and has been stalking me for weeks. He's probably off his medicines. His case manager and the police won't do anything." In which order should the following nursing actions be done from fi rst to last? 2. Assess the client's risk for harm to self and others. 3. Obtain the name of her ex-husband's case manager. 4. Interview the client about her current needs and situatio

The nurse should fi rst assess the client's risk for harm, especially because the client could direct her anger to her ex-husband or the nurse. Then it is important to know more about her current situation and her immediate needs. Obtaining information from the ex-husband's case manager might help clarify the risk of harm to the client. Problems leading to the divorce are less important than the situation following the divorce.

Voyeurism

This behavior involves "peeping," for the purpose of sexual excitement, at unsuspecting people who are nude, undressing, or engaged in sexual activity.

Mr. Lim who is diagnosed of moderate dementia has frequent catastrophic reactions during shower time. Which of the following interventions should be implemented in the plan of care? Select all that apply. Assign consistent staff members to assist the client. Accomplish the task quickly, with several staff members assisting. Schedule the client's shower at the same time of day. Sedate the client 30 minutes prior to showering. Tell the client to remain calm while showering. Use a calm, supportive, quiet manner when assisting the client.

Use a calm, supportive, quiet manner when assisting the client.

Heroin • Morphine • Codeine • Opium • Methadone Withdrawal

Watery eyes, runny nose, dilated pupils • Anxiety • Diaphoresis, fever • Nausea, vomiting, and diarrhea • Achiness • Abdominal cramps • Insomnia • Tachycardia

What is a frequently occurring nursing diagnosis for a caregiver of someone with Alzheimer's disease

What is a frequently occurring nursing diagnosis for a caregiver of someone with Alzheimer's disease