EAQ Behavior N4410

After an automobile accident a person is arrested for driving while intoxicated and is admitted to the hospital. When the client becomes angry and blames the family for personal problems, the nurse can be most therapeutic by using which statement?

"I can see that you're upset about your family, but we need to focus on what you need right now."

A client who was in an automobile accident is admitted to the hospital with multiple injuries. Approximately 14 hours after admission, the client begins to experience signs and symptoms of withdrawal from alcohol. Which songs and symptoms should the nurse connect to alcohol withdrawal? Select all that apply.

Anxiety Diaphoresis Psychomotor agitation Rationale: Anxiety is commonly associated with withdrawal from alcohol. When a person is withdrawing from alcohol, associated autonomic hyperactivity causes an increased heart rate and diaphoresis. The withdrawal of alcohol affects the central nervous system, resulting in excited motor activity. Fatigue is associated with withdrawal from caffeine or stimulants. A runny nose and tearing of the eyes are associated with withdrawal from opioids.

A married woman is brought to the emergency department of a local hospital. Her eyes are swollen shut, and she has a bruise on her neck. She reports that she is being beaten by her husband. How does the nurse expect the husband to behave when he arrives at the emergency department?

Charming Rationale: Abusers are often extremely charming to mask their abusive tendencies and convince the abused mate and others that change is possible. After an abusive episode there is often a "honeymoon" period because the tensions of the abuser have been released. Abusers mask their fears by becoming angry and aggressive. Abusers are not confused; they are manipulative of others. Abusers are rarely indifferent; they tend to be opinionated and demanding.

Nurses on a psychiatric unit have secluded a client who has the diagnosis of bipolar I disorder, manic episode, and who has been losing control and throwing objects while in the dayroom. What is the mostimportant intervention for the client who is given an as-needed (PRN) medication and confined to involuntary seclusion?

Evaluate the client's process toward self-control. Rationale: For the safety of the client and everyone on the unit, improvement in a client's level of self-control is essential before the degree of restraint and seclusion is progressively reduced. Continuing intensive interaction at this time would not be productive and could cause the client's behavior to escalate. The nurse's prime responsibility should be the client; staff members can assess other staff members. Observing the client for side effects of medications is only one of the many factors in determining the client's level of self-control.

Risk for assaultive behavior is highest in the mental health client who does what?

Experiences command hallucinations. Rationale: Command hallucinations are dangerous because they may influence the client to engage in behaviors that are dangerous to self or others. Although profane language, excessive touching of others, and withdrawn behavior may all be cause for concern, none are as dangerous as command hallucinations.

HTe nurse is assess a client being teated in the emergency department for minor injuries resulting form a mugging and robbery. Which action should the nurse do first?

Explain that feeling anxious is a common response to such an experience. Rationale: The initial intervention is to help the client identify and deal with the emotional and physical reactions to the recent trauma. Explaining that feeling anxious is a common response to such an experience will facilitate the relaxation process for the client. Encouraging deep breathing and other relaxation techniques and creating a low-stimulus environment are appropriate in cases of anxiety, but these would not be the initial interventions in this situation. Although addressing safety issues is appropriate in cases of anxiety-induced dizziness, dedicating a staff member to that task is neither realistic or necessary in this situation.

What medication does the nurse expect to administer to actively reverse the overdose sedative effects of benzodiazepines?

Flumazenil

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

Intramuscular injections of thiamine. Rationale: Thiamine is a coenzyme necessary for the production of energy from glucose. If thiamine is not present in adequate amounts, nerve activity is diminished and damage or degeneration of myelin sheaths occurs. A traditional phenothiazine is a neuroleptic antipsychotic that should not be prescribed because it is hepatotoxic. Antipsychotics are avoided; the use of these has a higher risk for toxic side effects in older or debilitated persons. Chlorpromazine, a neuroleptic, will not be used because it is severely toxic to the liver.

An adolescent has pinpoint pupils, respiratory depression, and cyanosis. Upon assessment, the school nurse observes needle marks on arms and legs. Which drug is the adolescent probably abusing?

Narcotics Rationale: Opioids such as morphine, heroin, codeine, and fentanyl are grouped under narcotic drugs. Physical signs of narcotic abuse include constricted pupils, respiratory depression and cyanosis. Cocaine creates a state of indefinable high or euphoria; withdrawal signs include depression, irritability, seizures, and cardiovascular manifestations. Hallucinogens produce vivid hallucinations and euphoria; they do not produce physical dependence. Clients with acute intoxication of central nervous system (CNS) stimulants may display aggressive behavior along with psychotic episodes of agitation and restlessness.

Thiamine (vitamin B1) and niacin (vitamine B3) are prescribed for a client with alcoholism. Which body function maintained by these vitamins should the nurse include in a teaching plan?

Neuronal activity Rationale: Thiamine and niacin help convert glucose for energy, and therefore influence nerve activity. These vitamins do not affect elimination. These vitamins are not related to circulatory activity. Vitamin K, not thiamine and niacin, is essential for the manufacture of prothrombin.

A young female client admitted to the trauma center after being sexually assaulted continues to talk about the rape. Toward what goal should the primary nursing intervention be directed?

Providing a safe environment that permits the ventilation of feelings. Rationale: The client needs to be able to express her current feelings. Providing an environment in which she feels safe will encourage this expression of feelings. It is too soon after the assault to discuss this topic in a group. Although the nurse should be available and supportive, feelings of anger are usually not the initial response. It is too soon after the assault to discuss her feelings about men and future relationships.

A client is admitted to the drug detoxification unit for cocaine withdrawal. What is the nurse's primary concern while working with clients withdrawing from cocaine?

Risk for self-injury Rationale: The greatest risk in cocaine withdrawal is risk for self-injury. The risk for seizure is increased while a person is under the influence of cocaine, not during withdrawal. Although dehydration may occur during cocaine use and withdrawal, it is not the priority concern. People in cocaine withdrawal, although irritable, are more apt to hurt themselves than others.

A nurse is caring for a client who has abruptly stopped taking a barbiturate. What withdrawal complication does the nurse anticipate that the client may experience?

Seizures Rationale: Seizures are a serious side effect that may occur with abrupt withdrawal from barbiturates. Ataxia, diarrhea, and urticaria are not associated with barbiturate withdrawal.

A client is responding within 5 minutes of receiving naloxone to combat respiratory depression from an overdose of heroin. Why will the nurse continue to closely monitor the client's status?

Symptoms of heroin overdose may return after the naloxone is metabolized. Rationale: When naloxone is metabolized and its effects are diminished, the respiratory distress caused by the original drug overdose returns. A combination of these drugs does not cause cardiac depression. There are no reports of peripheral neuropathy or hyperexcitability and amnesia with naloxone.

A recently married 22-year-old woman is brought to the trauma center by the police. She has been robbed, beaten, and sexually assaulted. The client, although anxious and tearful, appears to be in control. The primary healthcare provider prescribes 0.25 mg of alprazolam for agitation. The nurse will administer this medication when what event occurs?

The client requests something to calm her. Rationale: Because a sexual assault is a threat to the sense of control over one's life, some control should be given back to the client as soon as possible. Crying is a typical way to express emotions; the client should be told that medication is available if desired. The nurse determining a need to reduce the client's anxiety or administering the medication when the primary healthcare provider is getting ready to do a vaginal examination takes control away from the client; the client may view these actions as an additional assault on the body, which increases feelings of vulnerability and anxiety and does not restore control.