What parental behavior toward a child during an admission procedure should cause Nurse Ron to suspect child abuse?
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Solution
Acting overly solicitous toward the child.
Option C: This behavior is an example of reaction formation, a coping mechanism.
Nurse Gina is aware that the dietary implications for a client in manic phase of bipolar disorder is:
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Solution
Increase calories, carbohydrates, and protein.
Option D: This client increased protein for tissue building and increased calories to replace what is burned up (usually via carbohydrates).
In preparing a female client for electroconvulsive therapy (ECT), Nurse Michelle knows that succinylcholine (Anectine) will be administered for which therapeutic effect?
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Solution
Skeletal muscle paralysis.
Option C: Anectine is a depolarizing muscle relaxant causing paralysis. It is used to reduce the intensity of muscle contractions during the convulsive stage, thereby reducing the risk of bone fractures or dislocation.
Dervid, an adolescent has a history of truancy from school, running away from home and “borrowing” other people’s things without their permission. The adolescent denies stealing, rationalizing instead that as long as no one was using the items, it was all right to borrow them. It is important for the nurse to understand the psychodynamically, this behavior may be largely attributed to a developmental defect related to the:
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Solution
Superego
Option C: This behavior shows a weak sense of moral consciousness. According to Freudian theory, personality disorders stem from a weak superego.
Aira has taken amitriptyline HCL (Elavil) for 3 days, but now complains that it “doesn’t help” and refuses to take it. What should the nurse say or do?
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Solution
Suggest that it takes awhile before seeing the results.
Option D: The client needs a specific response; that it takes 2 to 3 weeks (a delayed effect) until the therapeutic blood level is reached.
What is Nurse John likely to note in a male client being admitted for alcohol withdrawal?
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Solution
Perceptual disorders.
Option A: Frightening visual hallucinations are especially common in clients experiencing alcohol withdrawal.
Dervid, an adolescent boy was admitted for substance abuse and hallucinations. The client’s mother asks Nurse Armando to talk with his husband when he arrives at the hospital. The mother says that she is afraid of what the father might say to the boy. The most appropriate nursing intervention would be to:
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Solution
Agree to talk with the mother and the father together.
Option C: By agreeing to talk with both parents, the nurse can provide emotional support and further assess and validate the family’s needs.
Tina who is manic, but not yet on medication, comes to the drug treatment center. The nurse would not let this client join the group session because:
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Solution
The client is disruptive.
Option A: Group activity provides too much stimulation, which the client will not be able to handle (harmful to self) and as a result will be disruptive to others.
Tony refuses his evening dose of Haloperidol (Haldol), then becomes extremely agitated in the dayroom while other clients are watching television. He begins cursing and throwing furniture. Nurse Oliver first action is to:
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Solution
Remove all other clients from the dayroom.
Option D: The nurse’s first priority is to consider the safety of the clients in the therapeutic setting.
Options A, B, and C: The other actions are appropriate responses after ensuring the safety of other clients.
Mr. Marquez reports of losing his job, not being able to sleep at night, and feeling upset with his wife. Nurse John responds to the client, “You may want to talk about your employment situation in group today.” The Nurse is using which therapeutic technique?
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Solution
Focusing
Option D: The nurse is using focusing by suggesting that the client discuss a specific issue.
Options A, B, and C: The nurse didn’t restate the question, make observation, or ask further question (exploring).