Which of the following signs should the nurse expect in a client with known amphetamine overdose?
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Solution
Tachycardia
Option B: Amphetamines are central nervous system stimulants. They cause sympathetic stimulation, including hypertension, tachycardia, vasoconstriction, and hyperthermia.
Option C: Hot, dry skin is seen with anticholinergic agents such as jimsonweed.
Option D: Pupils will be dilated, not constricted.
The nurse is providing care for a client undergoing opiate withdrawal. Opiate withdrawal causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with:
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Solution
methadone.
Option C: Methadone is used to detoxify opiate users because it binds with opioid receptors at many sites in the central nervous system but doesn’t have the same deleterious effects as other opiates, such as cocaine, heroin, and morphine.
Options A, B, and D: Barbiturates, amphetamines, and benzodiazepines are highly addictive and would require detoxification treatment.
During a private conversation, a client with borderline personality disorder asks the nurse to keep his secret and then displays multiple, self-inflicted, superficial lacerations on the forearms. What is the nurse’s best response?
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Solution
“The team needs to know when something important occurs in treatment. I need to tell the others, but let’s talk about it first.”
Option D: This response informs the client of the nurse’s planned actions and allows time to discuss the client’s actions.
Options A and B: Put the client on the defensive and may lead to a power struggle.
Option C: This ignores the psychological implications of the client’s actions.
On discharge after treatment for alcoholism, a client plans to take disulfiram (Antabuse) as prescribed. When teaching the client about this drug, the nurse emphasizes the need to:
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Solution
avoid all products containing alcohol.
Option A: To avoid severe adverse effects, the client taking disulfiram must strictly avoid alcohol and all products that contain alcohol.
Options B and C: Vitamin B therapy and blood monitoring aren’t necessary during disulfiram therapy.
A client is brought to the emergency department after being beaten by her husband, a prominent attorney. The nurse caring for this client understands that:
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Solution
domestic violence and abuse span all socioeconomic classes.
Option C: Domestic violence and abuse affect all socioeconomic classes.
Options A and B: Closed boundaries and an imbalance of power, with one member having control over the others, are common in violent families.
Option D: Although violent behavior may be passed from one generation to the next, it’s a learned behavior, not a genetic trait.
A 16-year-old boy is admitted to the facility after acting out his aggressions inappropriately at school. Predisposing factors to the expression of aggression include:
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Solution
violence on television.
Option A: Violence on television has been correlated with an increase in aggressive behavior.
Option B: Passive parents contribute to acting-out behaviors but not specifically to violence.
Option C: An internal locus of control leads to a positive sense of self-esteem and isn’t related to violence or aggression.
Option D: There is no direct correlation between single-parent families and violence.
A client is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but he can control his use if he chooses. Which coping mechanism is he using?
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Solution
Denial
Option D: Denial is an unconscious defense mechanism in which emotional conflict and anxiety are avoided by refusing to acknowledge feelings, desires, impulses, or external facts that are consciously
intolerable.Option A: Withdrawal is a common response to stress, characterized by apathy.
Option B: Logical thinking IS the ability to think rationally and make responsible decisions, which would lead the client to admitting the problem and seeking help.
Option C: Repression is suppressing past events from the consciousness because of guilty association.
Which of the following etiologic factors predispose a client to Tourette syndrome?
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Solution
Abnormalities in brain neurotransmitters, structural changes in basal ganglia and caudate nucleus, and genetics
Option B: The etiology of Tourette syndrome includes genetics, abnormalities in neurotransmission, and structural changes in the basal ganglia and caudate nucleus.
Options C and D: The ventricles in the brain, environmental factors, and birth trauma aren’t involved.
A client tells the nurse that he is having suicidal thoughts every day. In conferring with the treatment team, the nurse should make which of the following recommendations?
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Solution
Intensive inpatient treatment
Option D: Inpatient care is the best intervention for a client who is thinking about suicide every day.
Option A: Implementing a no-suicide contract is an important strategy, but this client requires additional care.
Option B: Weekly therapy wouldn’t provide the intensity of care that this case warrants.
Option C: Obtaining a second opinion would take time; this client requires immediate intervention.