A male adult client voluntarily admits himself to the substance abuse unit. He confesses that he drinks one (1) qt or more of vodka each day and uses cocaine occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this condition?
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Solution
Diaphoresis, tremors, and nervousness
Alcohol withdrawal syndrome includes alcohol withdrawal, alcoholic hallucinosis, and alcohol withdrawal delirium (formerly delirium tremens). Signs of alcohol withdrawal include diaphoresis, tremors, nervousness, nausea, vomiting, malaise, increased blood pressure and pulse rate, sleep disturbance, and irritability.
Option A: Although diarrhea may be an early sign of alcohol withdrawal, tachycardia — not bradycardia — is associated with alcohol withdrawal.
Option B: Dehydration and an elevated temperature may be expected, but a temperature above 101° F indicates an infection rather than alcohol withdrawal. Pruritus rarely occurs in alcohol withdrawal.
Option C: If withdrawal symptoms remain untreated, seizures may arise later.
A male client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from nurse Julia?
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Solution
“Tell me how you feel about the accident.”
An open-ended statement or question is the most therapeutic response. It encourages the widest range of client responses, makes the client an active participant in the conversation, and shows the client that the nurse is interested in his feelings.
Option A: Asking the client why he drove while intoxicated can make him feel defensive and intimidated.
Option C: A judgmental approach isn’t therapeutic.
Option D: By giving advice, the nurse suggests that the client isn’t capable of making decisions, thus fostering dependency.
Nurse Fey is aware that the drug of choice for treating Tourette syndrome?
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Solution
Haloperidol (Haldol)
Haloperidol is the drug of choice for treating Tourette syndrome.
Options A, B, and D: Prozac, Luvox, and Paxil are antidepressants and aren’t used to treat Tourette syndrome
A 14-year-old client was brought to the clinic by her mother. Her mother expresses concern about her daughter’s weight loss and constant dieting. Nurse Kris conducts a health history interview. Which of the following comments indicates that the client may be suffering from anorexia nervosa?
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Solution
“I just can’t seem to get down to the weight I want to be. I’m so fat compared to other girls.”
Low self-esteem is the highest risk factor for anorexia nervosa. Constant dieting to get down to a “desirable weight” is characteristic of the disorder. Feeling inadequate when compared to peers indicates poor self-esteem.
Option A: Most clients with anorexia nervosa don’t like the way they look, and their self-perception may be distorted. A girl with cachexia may perceive herself to be overweight when she looks in the mirror.
Option B: Preferring fast food over healthy food is common in this age-group.
Option D: Because of the absence of body fat necessary for proper hormone production, amenorrhea is common for a client with anorexia nervosa.
A male client with a history of cocaine addiction is admitted to the coronary care unit for evaluation of substernal chest pain. The electrocardiogram (ECG) shows a 1-mm ST-segment elevation the anteroseptal leads and T-wave inversion in leads V3 to V5. Considering the client’s history of drug abuse, nurse Greg expects the physician to prescribe:
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Solution
Nitroglycerin (Nitro-Bid IV).
The elevated ST segments in this client’s ECG indicate myocardial ischemia. To reverse this problem, the physician is most likely to prescribe an infusion of nitroglycerin to dilate the coronary arteries.
Options A and B: Lidocaine and procainamide are cardiac drugs that may be indicated for this client at some point but aren’t used for coronary artery dilation.
Option D: If a cocaine user experiences ventricular fibrillation or asystole, the physician may prescribe epinephrine. However, this drug must be used with caution because cocaine may potentiate its adrenergic effects.
Clonidine (Catapres) can be used to treat conditions other than hypertension. Nurse Sally is aware that the following conditions might the drug be administered?
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Solution
Opiate withdrawal
Clonidine is used as adjunctive therapy in opiate withdrawal.
Option A: Benzodiazepines and neuroleptic agents are typically used to treat PCP intoxication.
Option B: Benzodiazepines, such as chlordiazepoxide (Librium), and neuroleptic agents, such as haloperidol, are used to treat alcohol withdrawal.
Option D: Antidepressants and medications with dopaminergic activity in the brain, such as fluoxetine (Prozac), are used to treat cocaine withdrawal.
Eighteen hours after undergoing an emergency appendectomy, a client with a reported history of social drinking displays these vital signs: temperature, 101.6° F (38.7° C); heart rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mm Hg. The client exhibits gross hand tremors and is screaming for someone to kill the bugs in the bed. Nurse Melinda should suspect:
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Solution
Alcohol withdrawal
The client’s vital signs and hallucinations suggest delirium tremens or alcohol withdrawal syndrome.
Options A, C, and D: Although infection, acute sepsis, and pneumonia may arise as postoperative complications; they wouldn’t cause this client’s signs and symptoms and typically would occur later in the postoperative course
A female client with anorexia nervosa describes herself as “a whale.” However, the nurse’s assessment reveals that the client is 5′ 8″ (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client’s unrealistic body image, which intervention should nurse Angel be included in the plan of care?
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Solution
Telling the client of the nurse’s concern for her health and desire to help her make decisions to keep her healthy
A client with anorexia nervosa has an unrealistic body image that causes consumption of little or no food. Therefore, the client needs assistance with making decisions about health.
Instead of protecting the client’s health, options A, B, and C may serve to make the client defensive and more entrenched in her unrealistic body image.
A male client is found sitting on the floor of the bathroom in the day treatment clinic with moderate lacerations on both wrists. Surrounded by broken glass, he sits staring blankly at his bleeding wrists while staff members call for an ambulance. How should Nurse Anuktakanuk approach her initially?
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Solution
Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her
Ensuring the safety of the client and the nurse is the priority at this time. Therefore, the nurse should approach the client cautiously while calling her name and talking to her in a calm, confident manner.
Option A: The nurse should keep in mind that the client shouldn’t be startled or overwhelmed. After explaining that the nurse is there to help, the nurse should observe the client’s response carefully.
Option B: If the client shows signs of agitation or confusion or poses a threat, the nurse should retreat and request assistance.
Option C: The nurse shouldn’t attempt to sit next to the client or examine injuries without first announcing the nurse’s presence and assessing the dangers of the situation.
The nurse is aware that the outcome criteria would be appropriate for a child diagnosed with oppositional defiant disorder?
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Solution
Accept responsibility for own behaviors
Children with oppositional defiant disorder frequently violate the rights of others. They are defiant, disobedient, and blame others for their actions. Accountability for their actions would demonstrate progress for the oppositional child.
Option B is incorrect as the oppositional child usually, focuses on his own needs.
Options C and D aren’t outcome criteria but interventions.