Rudolf is admitted for an overdose of amphetamines. When assessing the client, the nurse should expect to see:
-
Solution
Tension and irritability
Option A: An amphetamine is a nervous system stimulant that is subject to abuse because of its ability to produce wakefulness and euphoria. An overdose increases tension and irritability.
Options B and C: These are incorrect because amphetamines stimulate norepinephrine, which increase the heart rate and blood flow.
Option D: Diarrhea is a common adverse effect so option D in is incorrect.
Nurse Mickey is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to:
-
Solution
Identify anxiety-causing situations
Option C: Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety.
Richard is admitted with a diagnosis of schizotypal personality disorder. Which signs would this client exhibit during social situations?
-
Solution
Paranoid thoughts
Option B: Clients with schizotypal personality disorder experience excessive social anxiety that can lead to paranoid thoughts.
Option A: Aggressive behavior is uncommon, although these clients may experience agitation with anxiety.
Option C: Their behavior is emotionally cold with a flattened affect, regardless of the situation.
Option D: These clients demonstrate a reduced capacity for close or dependent relationships.
Ramon is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but that he can control his use if he chooses. Which coping mechanism is he using?
-
Solution
Denial
Option D: Denial is unconscious defense mechanism in which emotional conflict and anxiety is 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 admitting the problem and seeking help.
Option C: Repression is suppressing past events from the consciousness because of guilty association.
Nurse Jen is caring for a male client with manic depression. The plan of care for a client in a manic state would include:
-
Solution
Listening attentively with a neutral attitude and avoiding power struggles.
Option D: The nurse should listen to the client’s requests, express willingness to seriously consider the request, and respond later. The nurse shouldn’t try to restrain the client when he feels the need to move around as long as his activity isn’t harmful.
Option A: High-calorie finger foods should be offered to supplement the client’s diet, if he can’t remain seated long enough to eat a complete meal. The nurse shouldn’t be forced to stay seated at the table to finish a meal.
Option B: The nurse should encourage the client to take short daytime naps because he expends so much energy.
Option C: The nurse should set limits in a calm, clear, and self-confident tone of voice.
Tim is admitted with a diagnosis of delusions of grandeur. The nurse is aware that this diagnosis reflects a belief that one is:
-
Solution
Highly important or famous.
Option A: A delusion of grandeur is a false belief that one is highly important or famous.
Option B: A delusion of persecution is a false belief that one is being persecuted.
Options C and D: A delusion of reference is a false belief that one is connected to events unrelated to oneself or a belief that one is responsible for the evil in the world.
Nurse Marco is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan?
-
Solution
Set up a strict eating plan for the client.
Option C: Establishing a consistent eating plan and monitoring the client’s weight are very important in this disorder.
Option A: The family and friends should be included in the client’s care.
Option B: The client should be monitored during meals-not given privacy.
Option D: Exercise must be limited and supervised.
Nurse Cristina is caring for a client who experiences false sensory perceptions with no basis in reality. These perceptions are known as:
-
Solution
Hallucinations
Option B: Hallucinations are visual, auditory, gustatory, tactile, or olfactory perceptions that have no basis in reality.
Option A: Delusions are false beliefs, rather than perceptions, that the client accepts as real.
Option C: Loose associations are rapid shifts among unrelated ideas.
Option D: Neologisms are bizarre words that have meaning only to the client.
Nurse Amy is providing care for a male 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:
-
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.
The nurse is caring for a client diagnosed with antisocial personality disorder. The client has a history of fighting, cruelty to animals, and stealing. Which of the following traits would the nurse be most likely to uncover during assessment?
-
Solution
A low tolerance for frustration
Option D: Clients with an antisocial personality disorder exhibit a low tolerance for frustration, emotional immaturity, and a lack of impulse control.
Option A: They commonly have a history of unemployment, miss work repeatedly, and quit work without other plans for employment.
Option B: They don’t feel guilty about their behavior and commonly perceive themselves as victims. They also display a lack of responsibility for the outcome of their actions.
Option C: Because of a lack of trust in others, clients with antisocial personality disorder commonly have difficulty developing stable, close relationships.