A client voluntarily admits himself to the substance abuse unit. He confesses that he drinks 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?
-
Solution
Diaphoresis, tremors, and nervousness
Option D: 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.
The client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from the nurse?
-
Solution
“Tell me how you feel about the accident.”
Option B: 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.
Which is the drug of choice for treating Tourette syndrome?
-
Solution
haloperidol (Haldol)
Option C: 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 15-year-old client is brought to the clinic by her mother. Her mother expresses concern about her daughter’s weight loss and constant dieting. The nurse conducts a health history interview. Which of the following comments indicates that the client may be suffering from anorexia nervosa?
-
Solution
“I just can’t seem to get down to the weight I want to be. I’m so fat compared to other girls.”
Option C: 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 in a client with anorexia nervosa.
A 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, the nurse expects the physician to prescribe:
-
Solution
nitroglycerin (Nitro-Bid IV).
Option C: 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.
In group therapy, a client who has used I.V. heroin every day for the past 14 years says, “I don’t have a drug problem. I can quit whenever I want. I’ve done it before.” Which defense mechanism is the client using?
-
Solution
Denial
Option A: A client who states that he or she doesn’t have a drug problem and can quit using drugs at any time — despite evidence to the contrary — is denying the drug addiction.
Option B: Obsession isn’t a defense mechanism.
Option C: In compensation, the client emphasizes positive attributes to compensate for negative ones.
Option D: In rationalization, the client justifies behaviors by faulty logic.
Which psychosocial influence has been causally related to the development of aggressive behavior and conduct disorder?
-
Solution
Rejection by peers
Option B: Studies indicate that children who are rejected by their peers are more likely to behave aggressively.
Options A and C: Schizophrenia and an overbearing mother haven’t been associated with aggression or conduct disorder.
Option D: Aggression and conduct disorder are represented in all socioeconomic groups.
The nurse is working with a client who abuses alcohol. Which of the following facts should the nurse communicate to the client?
-
Solution
Abstinence is the basis for successful treatment.
Option A: The foundation of any treatment for alcoholism is abstinence.
Option B: Attendance at Alcoholics Anonymous is helpful to some individuals to maintain strict abstinence.
Option C: Participation in treatment by the family is beneficial to both the client and the family but isn’t essential.
Option D: Abstinence requires refraining from social drinking.
Which nursing action is best when trying to diffuse a client’s impending violent behavior?
-
Solution
Helping the client identify and express feelings of anxiety and anger
Option A: In many instances, the nurse can diffuse impending violence by helping the client identify and express feelings of anger and anxiety. Such statements as “What happened to get you this angry?” may help the client verbalize feelings rather than act on them.
Option B: Close interaction with the client in a quiet activity may place the nurse at risk for injury should the client suddenly become violent.
Option C: An agitated and potentially violent client shouldn’t be left alone or unsupervised because the danger of the client acting out is too great.
Option D: The client should be placed in seclusion only if other interventions fail or the client requests this. Unlocked seclusion can be helpful for some clients because it reduces environmental stimulation and provides a feeling of security.
A client is admitted to the psychiatric unit with a diagnosis of alcohol intoxication and suspected alcohol dependence. Other assessment findings include an enlarged liver, jaundice, lethargy, and rambling, incoherent speech. No other information about the client is available. After the nurse completes the initial assessment, what is the first priority?
-
Solution
Instituting seizure precautions, obtaining frequent vital signs, and recording fluid intake and output
Option A: A nurse who lacks adequate information to determine which level of care a client requires must take all possible precautions to ensure the client’s physical safety and prevent complications. To do otherwise could place the client at risk for potential complications.
Options B and C: After taking all possible precautions, the nurse can begin seeking health history information and, as needed, modify the plan of care.
Option D: Fluids are typically increased unless contraindicated by a preexisting medical condition.
The nurse is caring for a client who she believes has been abusing opiates. Assessment findings in a client abusing opiates such as morphine include:
-
Solution
euphoria and constricted pupils.
Option D: Assessment findings in a client abusing opiates include agitation, slurred speech, euphoria, and constricted pupils.