My Exam 4 review

Which interventions are most appropriate for caring for a client in alcohol withdrawal? SELECT ALL THAT APPLY! A. Monitor vital signs B. Provide a safe environment C. Address hallucinations therapeutically D. Provide stimulation in the environment E. Provide reality orientation as appropriate F. Maintain NPO status

A, B,C, E

The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority information should be included in the discharge instructions? A. Information regarding shelters B. Instructions regarding calling the police C. Instructions regarding self-defense classes D. Explaining the importance of leaving the violent situation

A. Information regarding shelters

The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, distracted, tremulous, and bewildered at times. How should the nurse interpret these behaviors? A. Signs of depression B. Reactions to a devastating event C. Evidence that the client is a high suicide risk D. Indicative of the need for hospital admission

B. Reactions to a devastating event

The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." Which is the most helpful response by the nurse? A. Why dont you tell your spouse about this? B. What do you find difficult about this situation? C. This is not the best time to make that decision. D. I agree with you. you should get out of this situation.

B. What do you find difficult about this situation?

The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating events that led to the crisis, which is the most appropriate question? A. With whom do you live? B. Who is available to help you? C. What leads you to seek help now? D. What do you usually do to feel better?

C. What leads you to seek help now?

An older adult has experienced both physical and emotional abuse while living with a family member. The family member has been adherent with required therapy and at the client's request the two will again be living together. Which intervention will best assure that both the client and the family member's needs are being met? A. The family member is informed that criminal charges will be filed if any abuse occurs. B. The client agrees to report any incidences of abuse by the family member immediately. C. Initially, 7 days a week, 24-hour home aides are provided. D. The home will have regular but unscheduled visits by adult protective services agents.

D. The home will have regular but unscheduled visits by adult protective services agents. Follow-up is crucial in ensuring ongoing safety of the elderly patient and support of the caregiving system. None of the other options provide long-term support and supervision.

Which statement indicates the existence of a codependent relation between a client diagnosed with substance abuse and their life partner? A. "I'm always so angry about how the addiction controls our lives." B. "Everyone knows about the addiction and it is so very embarrassing." C. "All our savings have been spent on rehab treatment." D. "They are the love of my life but it's so hard living together."

A. "I'm always so angry about how the addiction controls our lives." Codependent individuals find their moods being influenced by the situation and the emotions of the abuser. While the other options reflect common characteristics of a relation involving substance abuse, they do not necessarily demonstrate a codependency.

Grief therapy was prescribed for a client who recently experienced tremendous grief upon the death of a parent. Which statement best demonstrates that a client is moving toward the healthy resolution of that grief? A. "I've enjoyed going to the book club my sister suggested." B. "My mother would want me to get back to living my life again." C. "I'm going to stop being sad and rely on my faith to support me." D. "I'm considering it's time to go back to work."

A. "I've enjoyed going to the book club my sister suggested." Ongoing evaluation will be performed until the crisis has resolved sufficiently to allow a return to normal pre-crisis functioning. As the patient's anxiety level reduces from severe to moderate to mild through successful interventions, the patient will need less support and return to independence. The correct option demonstrates independence, social engagement, and a return of enjoyment to one's life. The remaining options demonstrate consideration associated with returning to the familiar life situations (work, faith-based comfort).

When planning a substance abuse information program for a local university, the nurse will prioritize which screening? A. Alcohol B. Stimulants C. Hallucinogens D. Inhalants

A. Alcohol Alcohol use disorder is the most common substance-use problem in the United States. The prevalence of alcohol use in the United States affects approximately 16.6 million people. While the other options identify substances being abused within our population, none are as prevalent as is alcohol abuse.

A hospitalized patient with a history of alcohol misuse tells the nurse , "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged 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 should the nurse take? A. Call the nursing supervisor B. Call security to block all exits C. Restrain the client until the primary health care provider can be reached D. Tell the client that the client can not return to this hospital again if the client leaves now.

A. Call the nursing supervisor

The nurse determines that the wife of an alcoholic client is benefitting from attending Al-Anon group if the nurse hears the wife make which statement? A. I no longer feel that I deserve the beatings my husband inflicts on me B. My attendance at my meetings has helped me see that I provoke my husbands violence C. I enjoy attending the meetings because they get me out of the house and away from my husband D. I can tolerate my husbands destructive behaviors now that I know they are common among alcoholics.

A. I no longer feel that I deserve the beatings my husband inflicts on me

After the admission interview and assessment, the emergency department nurse has reason to believe that a child is being abused physically. Which intervention will the nurse implement to best determine if the child has been abused? A. Insist that the child be further assessed without the parents being present. B. Delay the assessment until the appropriate child protection authorities are present. C. Allow the child to pick one parent to be present during the remaining examination. D. Provide the child with suggestions of other possible examples of abuse.

A. Insist that the child be further assessed without the parents being present. In the case of suspected child abuse, after the initial interview with the parents, the child should be seen alone giving him or her a chance to disclose mistreatment. The child should not be prompted about possible abuse nor should the examination be delayed since these actions can affect the outcome of the assessment.

Which client statement reflects resiliency associated with a situational crisis he or she is experiencing? A. "I wasn't planning on another pregnancy but I would never consider an abortion." B. "Losing my son is so hard but when my father died, grief counseling really helped." C. "Retirement is something I had always dreaded but so far it's been pretty enjoyable." D. "When my son died in the flood, I depended on my family and friends for support."

B. "Losing my son is so hard but when my father died, grief counseling really helped." Situational crises are somewhat common, and at least some of them, like experiencing a loss through death, will be experienced by all individuals during their lifetime. Response to the situation depends in part upon the degree of support available. The existence of caring friends, family members, and groups as well as previous success in navigating life events (resiliency), and the overall physical and emotional health of the individual all contribute to an individual's resiliency. The correct option represents both a situational crisis and resiliency based in a past experience. Retirement is a maturational crisis, and the option demonstrates acceptance but not resiliency. While the pregnancy is a situational crisis, the option demonstrates a value but not resilience. The death of a loved one in a flood is an example of an adventitious crisis and the option doesn't demonstrate a past experience upon which to rely.

A nurse is discussing the possible existence of abuse related to a 4 year old currently being treated in the emergency department. Which statement by the nurse requires immediate intervention? A. "We don't need physical proof of injury to report this situation." B. "A 4 year old can be an unreliable source since they have such wonderful imaginations." C. "It's up to the state's child protection agency to determine if our fears are valid." D. "I'm absolutely sure every state requires that we report our concerns."

B. A 4 year old can be an unreliable source since they have such wonderful imaginations." When child abuse is suspected, persons in authority including nurses, teachers, spiritual leaders, coaches, counselors, and child care providers are legally responsible for reporting to the appropriate child protective agency. Each state mandates that a report must be filed when suspected abuse or neglect is encountered. It is not necessary to have proof of the abuse. If there is a suspicion or the child says something is happening, that is enough grounds to report. It is then up to the CPS agency to investigate and make a determination.

The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? A. Ask the client why he started taking illegal drugs. B. Ask the client about the amount of drug use and its effect. C. Ask the client how long he thought that he could take drugs without someone finding out. D. Do not ask any questions for fear that the client is in denial and will throw the nurse out of the home.

B. Ask the client about the amount of drug use and its effect.

The police arrive at the emergency department with a client who has lacerated both wrists. Which is the initial nursing action? A. Administer an antianxiety agent. B. Assess and treat the wound sites C. Secure and record a detailed history D. Encourage and assist the client to ventilate feelings.

B. Assess and treat the wound sites

Which statement made by a client receiving treatment for a substance abuse problem best indicates an understanding of relapse prevention? A. "A good time always meant being with friends who abused like I did." B. "I abuse when I'm bored or lonely but now I know how to keep busy." C. "My family has helped me so much in staying sober." D. "I want so much to stop abusing."

B. I abuse when I'm bored or lonely but now I know how to keep busy." The goal of relapse prevention is to help individuals identify their "trigger situations" so that periods of sobriety can be lengthened over time and lapses and relapses are not viewed as total failures. Identifying both the trigger and a plausible strategy makes that option the best one. The remaining options are more associated with the client's feelings about the addiction.

There is reason to believe that a client unknowingly ingested flunitrazepam prior to being sexually assaulted. Which intervention will the nurse implement in order to confirm this suspicion? A. Obtain a bedside electrocardiogram. B. Obtain a urine sample. C. Assess what the client drank before the assault. D. Assess the client's pupils.

B. Obtain a urine sample. Assessment for "date rape" drugs like flunitrazepam should be included if description of the event indicates that possibility (loss of consciousness, vomiting). In such a case, a urine sample may be obtained. The remaining options are not directly associated with such an assessment.

A client is seeking treatment in the emergency department (ED) after a sexual assault. Which notation made by the ED nurse demonstrates appropriate nonjudgmental documentation? A. An alleged sexually assaulted inside a local parking garage was made by the client. B. Physical evidence supports that vaginal penetration occurred. C. Treatment for facial abrasions was refused. D. No acute emotional distress during assessment was noted.

B. Physical evidence supports that vaginal penetration occurred. Pejorative terms often reflect old myths and a lack of knowledge and understanding regarding the rape victim's experience and need for immediate intervention. Words and phrase like "alleged," "refused," "intercourse," and "no acute distress" all minimize the devastation of the event. Penetration is the preferred term when describing the sexual aspects of the assault.

When considering substance abuse, which individual is at the greatest risk for developing functional deficits in the future? A. The 45 year old with a 10-year history of heroin abuse B. The 15 year old abusing cannabis C. The 60 year old who has been dependent on sedatives for 15 years D. The 28 year old with a cocaine habit

B. The 15 year old abusing cannabis While the substance abuse identified in all the clients has resulted in some form of dysfunction, the teenager is at greatest risk for developing functional deficients. The brain doesn't fully mature until the mid-twenties; therefore, substances of abuse can interfere with brain ability to function in the future. Ingestion of drugs during youth and teenage years can also interfere with psychological/social growth, decrease the potential for a productive future, and terminate the life span of too many children and teenagers.

A client, being cared for in the emergency department (ED) after a sexual assault, asks that a friend be allowed to stay in the examination room while waiting for the SANE nurse to arrive. The client is observably anxious and states, "I don't want to be alone." What response will the ED nurse make in order to best assure the client's safety and emotional health? A. "I understand. I'll stay with you." B. "Are you thinking about hurting yourself?" C. "Certainly; whatever makes you feel safe." D. "Do you want to talk to a psychiatrist?"

C. "Certainly; whatever makes you feel safe." Having someone stay with the patient (friend, neighbor, sexual assault advocate, or staff member) while waiting to be treated is a priority intervention. People in high levels of anxiety need someone with them until their anxiety level is down to moderate. Never leave the individual alone. While the remaining options may become appropriate, the client has not yet demonstrated behaviors to warrant implementing either one.

A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which is the most appropriate nursing response? A. "You need to try to be realistic. The rape did not just occur." B. "It will take some time to get over these feelings about your rape. C. "Tell me more about the incident that causes you to feel like the rape just occurred." D. "What do you think that you can do to alleviate some of your fears about being raped again?"

C. "Tell me more about the incident that causes you to feel like the rape just occurred.

Which assessment question will provide the nurse with information concerning the client's perception of the situational crisis of losing their job? A. "Do you have a plan for meeting your financial obligations while unemployed?" B. "Have you ever been out of a job before?" C. "How much will being unemployed for several months affect your life?" D. "Who can you rely upon for help while you are looking for a job?"

C. How much will being unemployed for several months affect your life?" Whether an event is perceived as a crisis is, in part, dependent on the outlook and strengths of the patient. Therefore it is important to view the event through the eyes of the patient. The nurse's initial task is to assess the individual's and possibly the family's perception of the problem. The correct option directly assesses the client's perception of the crisis. While the other options are not inappropriate, they don't focus on perception

A client has been receiving treatment for posttraumatic stress disorder (PTSD) after experiencing a sexual assault. Which statement supports that the client is able to resume pre-trauma function? A. "I really like my therapist." B. "I'm hopeful that life will get back to normal." C. "I'm being considered for a promotion at work." D. "I'm feeling less anxious among strangers."

C. I'm being considered for a promotion at work." Most patients will be able to eventually resume their previous lives after supportive services and crisis counseling or therapy. If survivors are relatively free of signs of PTSD and their lifestyles are close to their lifestyles before the rape, the recovery is considered successful. Being considered for a promotion indicates the client is able to effectively work and engage in areas of interest. The remaining options, while positive statements, lack tangible proof of resuming pre-trauma levels of functioning.

A client has recently lost all his or her possessions in a fire a month ago. Which assessment data suggests that hospitalization should be considered? A. Has gained 10 pounds since the fire. B. Drinks a six pack of beer daily. C. States, "The fire made my life so hopeless." D. Reports, "I really do need someone to talk to."

C. States, "The fire made my life so hopeless." In crisis situations, it is important to evaluate the person's level of anxiety. Common coping mechanisms may be overeating, drinking, smoking, withdrawing, seeking out someone to talk to, crying, yelling, sleeping too much, praying, or engaging in other physical activity. The potential for suicide or homicide must be assessed. If the patient is thinking of harming themself or someone else, or is unable to take care of personal needs, hospitalization should be considered. The correct option demonstrates a potential risk for suicide.

A nurse is conducting a family assessment to identify possible triggers for abusive behaviors. Which family characteristic will the nurse identify as such a trigger? A. The father is the "stay-at-home parent." B. The parents are of different ethnic and religious backgrounds. C. The parents were teenagers when the children were born. D. The family only socializes with other immigrant families.

C. The parents were teenagers when the children were born. The classic frustration-aggression hypothesis proposes that when frustration is high in response to negative societal situations, frustration may lead to aggression. Early parenthood is considered such a stressor. None of the other options are recognized as triggers for possible family-centered abuse.

Which statement best demonstrates a client's understanding of how years of addiction have affected their ability to mature normally? A. "My years of addiction allowed me to avoid being a mature person." B. "Taking on grown up responsibilities is certainly a challenge." C. "I don't think I've ever had to think like an adult before." D. "I've got to learn how to address my problems like an adult would."

D. "I've got to learn how to address my problems like an adult would." Alcohol and drug addiction will interrupt an individual's progression through the maturational stages. As the patient escapes from stressors through the use of substances, he or she is not practicing communication and coping skills that contribute to maturity. When the individual gets clean and sober, he or she will discover that his or her maturation has been halted at about the age he or she began using drugs or alcohol. The good news is that the developmental process can resume and progress through supportive treatment. The correct option demonstrates an understanding of personal deficits and a need to address them, while the other options are statements of facts.

A client has expressed great concern over "feeling like I'm going crazy" since experiencing anxiety, depression, and nightmares after being sexually assaulted. What response will the nurse make initially to address the client's concerns? A. "What you are experiencing is common among assault victims. It's not a result of going crazy." B. "Let's talk about how these symptoms are making you feel and especially how they are making you feel crazy." C. "These are common feelings after being assaulted. Fortunately you are not going crazy so try not to worry." D. "What you are experiencing must be frightening. These symptoms are shared by many who have been sexually assaulted."

D. "What you are experiencing must be frightening. These symptoms are shared by many who have been sexually assaulted." Many individuals think they are going crazy and are not aware that this is a process that many people in their situation have experienced. Explain to the patient that the signs and symptoms that many people experience during the long-term phase include nightmares, anxiety, and depression. The correct option is the only one that gives the client the needed information while also acknowledging his or her feelings.

The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor? A. A crisis state indicates that the client has a mental illness. B. A crisis state indicates that the client has an emotional illness. C. Presenting symptoms in a crisis situation are similiar for all clients experiencing a crisis. D. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.

D. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.

Which question demonstrates the nurse's understanding of the need to assess a client who has been physically abused for additional forms of trauma? A. "What types of injuries have you received as a result of the physical abuse?" B. "Do you know what triggers the physical abuse?" C. "Did your abuser ever intimidate or threaten you with physical harm?" D. "Can you tell me when the physical abuse began?"

D. Can you tell me when the physical abuse began?" The physical damage caused by physical abuse is usually accompanied by emotional abuse. Emotional abuse includes threats and intimidation. The remaining options focus on the physical abuse/trauma.

To monitor for a significant health risk, the nurse will prepare to implement which intervention for a client admitted for alcohol detoxification? A. 24-hour urine test B. Nutritional consult C. Falls assessment D. Cardiac consult

D. Cardiac consult Patients with a co-occurring/comorbid dual diagnosis have more severe symptoms, experience more crises, and require longer treatment. Cardiovascular risks are also significant. Alcohol can raise the levels of triglycerides in the blood. Excessive alcohol intake results in stroke, cardiomyopathy, cardiac dysrhythmia, and sudden cardiac death. While the remaining options may not be inappropriate for some clients being admitted for alcohol-related treatment, the cardiac risks are the most significant.

The nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? A. Hypotension, ataxia, hunger B. Stupor, lethargy, muscular rigidity C. Hypotension, coarse hand tremors, lethargy D. Hypertension, changes in level of consciousness, hallucinations

D. Hypertension, changes in level of consciousness, hallucinations