The initial nursing intervention for the significant-others during shock phase of a grief reaction should be focused on:
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Solution
Staying with the individuals involved
Option C: This provides support until the individuals coping mechanisms and personal support systems can be immobilized.
The nursing assistant tells nurse Ronald that the client is not in the dining room for lunch. Nurse Ronald would direct the nursing assistant to do which of the following?
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Solution
Invite the client to lunch and accompany him to the dining room
Option B: The nurse instructs the nursing assistant to invite the client to lunch & accompany him to the dining room to decrease manipulation, secondary gain, dependency and reinforcement of negative behavior while maintaining the client’s worth.
When developing a plan of care for a female client with acute stress disorder who lost her sister in a car accident. Which of the following would the nurse expect to initiate?
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Solution
Facilitating progressive review of the accident and its consequences
Option A: The nurse would facilitate progressive review of the accident and its consequence to help the client integrate feelings & memories and to begin the grieving process.
Which of the following liquids would nurse Leng administer to a female client who is intoxicated with phencyclidine (PCP) to hasten excretion of the chemical?
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Solution
Cranberry Juice
Option C: An acid environment aids in the excretion of PCP. The nurse will definitely give the client with PCP intoxication cranberry juice to acidify the urine to a ph of 5.5 & accelerate excretion.
Jose is diagnosed with amphetamine psychosis and was admitted to the emergency room. Nurse Ronald would most likely prepare to administer which of the following medication?
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Solution
Haldol
Option D: The nurse would prepare to administer an antipsychotic medication such as Haldol to a client experiencing amphetamine psychosis to decrease agitation & psychotic symptoms, including delusions, hallucinations & cognitive impairment.
Joey who has a chronic user of cocaine reports that he feels like he has cockroaches crawling under his skin. His arms are red because of scratching. The nurse in charge interprets these findings as possibly indicating which of the following?
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Solution
Formication
Option B: The feeling of bugs crawling under the skin is termed as formication, and is associated with cocaine use.
A female client is brought by ambulance to the hospital emergency room after taking an overdose of barbiturates is comatose. Nurse Trish would be especially alert for which of the following?
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Solution
Respiratory failure
Option D: Barbiturates are CNS depressants; the nurse would be especially alert for the possibility of respiratory failure. Respiratory failure is the most likely cause of death from barbiturate overdose.
Which of the following would nurse Ronald use as the best measure to determine a client’s progress in rehabilitation?
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Solution
The number of drug-free days he has
Option B: The best measure to determine a client’s progress in rehabilitation is the number of drug-free days he has. The longer the client is free of drugs, the better the prognosis is.
After administering naloxone (Narcan), an opioid antagonist, Nurse Ronald should monitor the female client carefully for which of the following?
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Solution
Respiratory depression
Option A: After administering naloxone (Narcan) the nurse should monitor the client’s respiratory status carefully, because the drug is short acting & respiratory depression may recur after its effects wear off.
Which of the following assessment would provide the best information about the client’s physiologic response and the effectiveness of the medication prescribed specifically for alcohol withdrawal?
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Solution
Vital signs
Option D: Monitoring of vital signs provides the best information about the client’s overall physiologic status during alcohol withdrawal & the physiologic response to the medication used.