The nurse is assessing a client on admission to the chemical dependency unit for alcohol detoxification. When the nurse asks about alcohol use, this client is most likely to:
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Solution
underestimate the amount consumed.
Option B: Most people who abuse substances underestimate their consumption in an attempt to conform to social norms or protect themselves.
Options A, C, and D: Few accurately describe or overestimate consumption; some may deny it. Therefore, on admission, quantitative and qualitative toxicology screens are done to validate information obtained from the client.
After completing chemical detoxification and a 12-step program to treat crack addiction, a client is being prepared for discharge. Which remark by the client indicates a realistic view of the future?
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Solution
“I’m going to take 1 day at a time. I’m not making any promises.”
Option C: Twelve-step programs focus on recovery 1 day at a time.
Option A: Such programs discourage people from claiming that they will never again use a substance because relapse is common.
Option B: The belief that one may use a limited amount of an abused substance indicates denial.
Option D: Substituting one abused substance for another predisposes the client to cross-addiction.
An attorney who throws books and furniture around the office after losing a case is referred to the psychiatric nurse in the law firm’s employee assistance program. The nurse knows that the client’s behavior most likely represents the use of which defense mechanism?
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Solution
Regression
Option A: An adult who throws temper tantrums, such as this one, is displaying regressive behavior, or behavior that is appropriate at a younger age.
Option B: In projection, the client blames someone or something other than the source.
Option C: In reaction formation, the client acts in opposition to his feelings.
Option D: In intellectualization, the client overuses rational explanations or abstract thinking to decrease the significance of a feeling or event.
The nurse in the substance abuse unit is trying to encourage a client to attend Alcoholics Anonymous meetings. When the client asks the nurse what he must do to become a member, the nurse should respond:
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Solution
“Admit you’re powerless over alcohol and that you need help.”
Option C: The first of the “Twelve Steps of Alcoholics Anonymous” is admitting that an individual is powerless over alcohol and that life has become unmanageable.
Option A: Although Alcoholics Anonymous promotes total abstinence, a client will still be accepted if he drinks.
Option B: A physician referral isn’t necessary to join.
Option D: New members are assigned a support person who may be called upon when the client has the urge to drink.
One of the goals for a client with anorexia nervosa is that the client will demonstrate increased individual coping by responding to stress in constructive ways. Which of the following actions is the best indicator that the client is working toward meeting the goal?
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Solution
The client keeps a journal and discusses it with the nurse.
Option C: The client is moving toward meeting the goal because recording and discussing feelings is a constructive way to manage stress.
Option A: Increased fluid intake may be an attempt by the client to curb her appetite and artificially increase her weight.
Option B: Although physical activity can reduce stress, the anorexic client is more likely to use pacing to burn calories and lose weight.
Option D: Although talks with friends can decrease stress, constant talking is more likely a way of avoiding dealing with problems.
Clonidine (Catapres) can be used to treat conditions other than hypertension. For which of the following conditions might the drug be administered?
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Solution
Opiate withdrawal
Option C: 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. The nurse should suspect:
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Solution
alcohol withdrawal.
Option B: 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 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 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
Option D: 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.
Options A, B, and C: 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 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, she sits staring blankly at her bleeding wrists while staff members call for an ambulance. How should the nurse 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.
Option D: 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. 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 A: 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.
Which outcome criteria would be appropriate for a child diagnosed with oppositional defiant disorder?
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Solution
Accept responsibility for own behaviors.
Option A: 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: This is incorrect as the oppositional child usually focuses on his own needs.
Options C and D: These aren’t outcome criteria but interventions.