Chapter 67: Addictions
A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa? 1. A client with pneumonia 2. A client undergoing diagnostic tests 3. A client who thrives on managing others 4. A client who could benefit from the client's assistance at mealtime
2. A client undergoing diagnostic tests Rationale: The client undergoing diagnostic tests is an acceptable roommate. The client with anorexia nervosa is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client with anorexia nervosa at risk for infection. The client with anorexia nervosa should not be put in a situation in which the client can focus on the nutritional needs of others or be managed by others because this may contribute to sublimation and suppression of personal hunger. Test-Taking Strategy: Note the strategic word, best, and note the words in a state of starvation in the question. Recalling the characteristics of anorexia nervosa and that the client is immunocompromised as a result of starvation will direct you to the correct option.
A hospitalized client with a history of alcohol use disorder tells the nurse: "I am leaving now. I must go. I do not want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action would the nurse take? 1. Call the nursing supervisor. 2. Call security to block all exit areas. 3. Restrain the client until the primary health care provider (PHCP) can be reached. 4. Tell the client that the client cannot return to this hospital again if the client leaves now.
1. Call the nursing supervisor. Rationale: Most health care facilities have documents that the client is asked to sign relating to the client's responsibilities when the client leaves against medical advice. The client would be asked to wait to speak to the PHCP before leaving and to sign the "against medical advice" document before leaving. If the client refuses to do so, the nurse cannot hold the client against the client's will. Therefore, in this situation, the nurse would call the nursing supervisor. The nurse can be charged with false imprisonment if clients are made to believe wrongfully that they cannot leave the hospital. Restraining the client and calling security to block exits constitutes false imprisonment. All clients have a right to health care and cannot be told otherwise. Test-Taking Strategy: Keeping the concept of false imprisonment in mind, eliminate options 2 and 3 because they are comparable or alike. Eliminate option 4, knowing that all clients have a right to health care. From the options presented, the best action is presented in the correct option.
Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. 1. Monitor vital signs. 2. Provide a safe environment. 3. Address hallucinations therapeutically. 4. Provide stimulation in the environment. 5. Provide reality orientation as appropriate. 6. Maintain NPO (nothing by mouth) status.
1. Monitor vital signs. 2. Provide a safe environment. 3. Address hallucinations therapeutically. 5. Provide reality orientation as appropriate. Rationale: When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming self or others. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake needs to be maintained. Test-Taking Strategy: Note the strategic words, most appropriate. Thinking about the needs of the client in alcohol withdrawal and recalling the characteristics associated with alcohol withdrawal will assist in answering correctly. Also, use therapeutic communication techniques to assist in selecting the correct interventions.
The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action would the nurse take to plan appropriate nursing care? 1. Ask the client why they started taking illegal drugs. 2. Ask the client about the amount of drug use and its effect. 3. Ask the client how long they thought that they could take drugs without someone finding out. 4. Not ask any questions for fear that the client is in denial and will throw the nurse out of the home.
2. Ask the client about the amount of drug use and its effect. Rationale: Whenever the nurse carries out an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect because it is judgmental and off-focus, and reflects the nurse's bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention. Test-Taking Strategy: Focus on the subject, providing appropriate nursing care. Use of therapeutic communication techniques will assist in directing you to the correct option.
The nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. Which findings would alert the nurse to the potential for alcohol withdrawal delirium? 1. Hypotension, ataxia, hunger 2. Stupor, lethargy, muscular rigidity 3. Hypotension, coarse hand tremors, lethargy 4. Hypertension, changes in level of consciousness, hallucinations
4. Hypertension, changes in level of consciousness, hallucinations Rationale: Symptoms associated with alcohol withdrawal delirium typically include hypertension, tachycardia, nausea and vomiting, tremors (especially in the hand), sweating, anxiety, agitation, tactile disturbances, hallucinations such as auditory or visual disturbances, headache, and disorientation. Test-Taking Strategy: Focus on the subject, findings associated with withdrawal delirium. Review each option carefully to ensure that all symptoms in the option are correct. Eliminate options 1 and 3 first, knowing that hypertension rather than hypotension occurs. From the remaining options, recalling that the client who is stuporous is unlikely to exhibit withdrawal delirium will direct you to the correct option.
The nurse is caring for a client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate? 1. Allow the client to complete the exercise program. 2. Interrupt the client and weigh the client immediately. 3. Tell the client that exercising rigorously is not allowed. 4. Interrupt the client and offer to take the client for a walk.
4. Interrupt the client and offer to take the client for a walk. Rationale: Clients with anorexia nervosa frequently are preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise and place limits on rigorous activities. The correct option stops the harmful behavior yet provides the client with an activity to decrease anxiety that is not harmful. Weighing the client immediately reinforces the client's preoccupation with weight. Allowing the client to complete the exercise program can be harmful to the client. Telling the client that completing the exercise is not allowed will increase the client's anxiety. Test-Taking Strategy: Note the strategic words, most appropriate, and focus on the client's diagnosis. Also, focus on the need for the nurse to maintain safety and to set firm limits with clients who have this disorder.
The nurse determines that the spouse of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the spouse make which statement? 1. "I no longer feel that I deserve the beatings my partner inflicts on me." 2. "My attendance at the meetings has helped me to see that I provoke my partner's violence." 3. "I enjoy attending the meetings because they get me out of the house and away from my partner." 4. "I can tolerate my partner's destructive behaviors now that I know they are common among alcoholics."
1. "I no longer feel that I deserve the beatings my partner inflicts on me." Rationale: Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavioral changes. The correct option is the healthiest response because it exemplifies an understanding that the alcoholic partner is responsible for their own behavior and cannot be allowed to blame family members for loss of control. Option 2 is incorrect because the nonalcoholic partner should not feel responsible when the spouse loses control. Option 3 indicates that the group is viewed as an escape, not as a place to work on issues. Option 4 indicates that the nonalcoholic partner remains codependent. Test-Taking Strategy: Focus on the subject, the therapeutic effect of attending an Al-Anon group. Noting the words benefiting from attending an Al-Anon group will direct you to the correct option.
The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings would the nurse expect to note? Select all that apply. 1. Dental decay 2. Moist, oily skin 3. Loss of tooth enamel 4. Electrolyte imbalances 5. Body weight well below ideal range
1. Dental decay 3. Loss of tooth enamel 4. Electrolyte imbalances Rationale: Clients with bulimia nervosa initially may not appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. On further inspection, a client exhibits dental decay and loss of tooth enamel if the client has been inducing vomiting. Electrolyte imbalances are present. Dry, scaly skin (rather than moist, oily skin) is present. Test-Taking Strategy: Focus on the subject, assessment findings in bulimia nervosa. It is necessary to recall that in anorexia nervosa the body weight is normally well below ideal body weight and that clients with bulimia nervosa are often at or slightly below ideal body weight. Also, remember that skin texture will be dry and scaly.
The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I need to get out of this bad situation." Which is the most helpful response by the nurse? 1. "Why don't you tell your spouse about this?" 2. "What do you find difficult about this situation?" 3. "This is not the best time to make that decision." 4. "I agree with you. You should get out of this situation.
2. "What do you find difficult about this situation?" Rationale: The most helpful response is one that encourages the client to solve problems. Giving advice implies that the nurse knows what is best and can foster dependency. The nurse would not agree with the client, and the nurse would not request that the client provide explanations. Test-Taking Strategy: Note the strategic word, most. Use therapeutic communication techniques. Eliminate option 1 because of the word why, which should be avoided in communication. Eliminate option 3 because this option places the client's feelings on hold. Eliminate option 4 because the nurse is agreeing with the client. The correct option is the only one that addresses the client's feelings.
A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes an interest in buying new clothes, but expresses that money is limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced personal caloric intake to 800 calories daily. How would the nurse evaluate this behavior? 1. Normal behavior 2. Evidence of the client's disturbed body image 3. Regression as the client is moving toward the community 4. Indicative of the client's ambivalence about hospital discharge
2. Evidence of the client's disturbed body image Rationale: Disturbed body image is a concern with clients with anorexia nervosa. Although the client may struggle with ambivalence and show regressed behavior, the client's coping pattern relates to the basic issue of disturbed body image. The nurse should address this need in the support group. Test-Taking Strategy: Note the subject, signs of disturbed body image. Note the relationship between the information in the question and the correct option.
