2
sedative effects of the drug peak while the client is sleeping. Options #2 and #4 do not offer concrete solutions and may fosterdependent behaviors. Option #3 may help to some degree, but a more concrete solution is possible.
8.
A client, admitted for treatment of alcohol dependence, displays the following symptoms: slurred speech, ataxia,uncoordinated movements, and headache. Which nursing action should be taken first?a.
Observe the client for 8 hours to collect additional data.b.
Perform a complete physical assessment.c.
Collect a urine specimen for a drug screen.d.
Encourage the client to talk about whatever is bothering him.
The best way to identify possible physical complications of alcohol dependence is through a complete physical assessment.Option #1 is important but will not provide the data that a physical assessment would. This may be a medical emergencyrequiring an immediate intervention. Option #3 is also a helpful source of data but can be done after the physical assessment isfinished. Option #4 is inaccurate since the symptoms are most likely caused by physical and not psychological stressors.
9.
When a client has dementia, which stressor would be identified as the most critical for the family?a.
Client s unwillingness to eat food with the family.b.
Client's inability to recognize and communicate with the family.c.
Lack of knowledge about community resources for day care.d.
Client's loss of continence.
This confirms a deteriorating condition and increases feelings of loss among family members. Options #1, #3, and #4 are allstressors for those dealing with a family member with dementia but are usually less critical.
10.
Before giving medication to a client who identifies himself as Jesus Christ, which action by the nurse is necessary?a.
Ask several nursing assistants to be available for safety.b.
Ask the priest to come and speak with the client.c.
Check the client's name band to make sure of the client's identity.d.
Make sure the client has eaten a full meal.
It is always necessary for the nurse to verify the client's identity before administering medications, particularly when the clientcannot verbalize his identity. Options #1, #2, and #4 will be unnecessary.
11.
Because of a borderline client's mood swings, limited problem-solving strategies, and self-concept disturbance, thetreatment team has determined the client is at high risk for violence, either directed at self or others. The nurse shouldobserve the client for early clues to which behavior?a.
Intense but disruptive relationshipsb.
Superficial interactions.c.
Persistent sense of boredom and loneliness.d.
Self-mutilation or suicidal gestures.
This is a common form of behavior displayed by the borderline client, which places her at a great risk for violence. Options #1, #2,and #3 are behaviors the client is likely to display, but they are not as clearly related to the high risk for violent behavior.
12.
Which symptom will the nursing assessment for a client with late AIDS dementia complex most likely reveal?a.
Hyperacute deep tendon reflexes.b.
Peripheral neuropathy affecting the hands.c.
Disorientation to person, place and time.d.
Impaired concentration and memory loss.
Approximately 65% of AIDS clients demonstrate a progressive dementia staged according to severity of debilitation. Late stage istypified by cognitive confusion and disorientation. Options #1 and #2 are not relevant to this condition. Option #4 is a sign of early onset dementia.
13.
An elderly man diagnosed with major depression is demonstrating decreased problem-solving ability, psychomotorretardation, and social isolation. In planning activities for this client during the early phase of hospitalization, which nursingaction would be appropriate?a.
Prepare and give him a schedule of activities to follow and monitor his participation.b.
Encourage him to choose his own activities.c.
Allow him some time to get acclimated to the milieu before scheduling activities.d.
Allow him to rest quietly to restore his energy
and
fatigue level.
A regular daily routine of scheduled activities provides structure and decreases the degree of problem-solving. Depressed clientsneed to have structure provided because of impairment in decision-making and problem-solving. Options #2, #3, and #4 maypromote further social isolation and increase the client's impairments. This may further decrease the client's self esteem.
14.
A suicide has occurred on an in-patient psychiatric unit. The staff members meet to discuss the suicide. What is the purposeof this meeting?a.
Review of the client's record by hospital administration.b.
Decide who will speak with the client's family members.c.
Allow ventilation of staff members' feelings and a review of the case.d.
Determine who is responsible for the break in observation.
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