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Question 1

Clonidine (Catapres) can be used to treat conditions other than hypertension. Nurse Sally is
aware that the following conditions might the drug be administered?

Phencyclidine (PCP) intoxication

Alcohol withdrawal

Opiate withdrawal

Cocaine withdrawal

Question 1 Explanation:
Clonidine is used as adjunctive therapy in opiate withdrawal. Benzodiazepines, such as
chlordiazepoxide (Librium), and neuropleptic agents, such as haloperidol, are used to treat
alcohol withdrawal. Benzodiazepines and neuropleptic agents are typically used to treat
PCP intoxication. Antidepressants and medications with dopaminergic activity in the brain,
such as fluoxotine (Prozac), are used to treat cocaine withdrawal.

Question 2
A male adult 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

Vomiting, diarrhea, and bradycardia

Dehydration, temperature above 101° F
(38.3° C), and pruritus

Hypertension, diaphoresis, and seizures

Diaphoresis, tremors, and nervousness

Question 2 Explanation:
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. Although diarrhea may be an early sign of
alcohol withdrawal, tachycardia — not bradycardia — is associated with alcohol withdrawal.
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. If withdrawal symptoms remain untreated, seizures may arise later.

Question 3
In the emergency department, a client with facial lacerations states that her husband beat
her with a shoe. After the health care team repairs her lacerations, she waits to be seen by
the crisis intake nurse, who will evaluate the continued threat of violence. Suddenly the
client’s husband arrives, shouting that he wants to “finish the job.” What is the first priority of
the health care worker who witnesses this scene?

Remaining with the client and staying

Calling a security guard and another staff
member for assistance

Telling the client’s husband that he must
leave at once

Determining why the husband feels so

Question 3 Explanation:
The health care worker who witnesses this scene must take precautions to ensure personal
as well as client safety, but shouldn’t attempt to manage a physically aggressive person
alone. Therefore, the first priority is to call a security guard and another staff member. After
doing this, the health care worker should inform the husband what is expected, speaking in
concise statements and maintaining a firm but calm demeanor. This approach makes it
clear that the health care worker is in control and may diffuse the situation until the security
guard arrives. Telling the husband to leave would probably be ineffective because of his
agitated and irrational state. Exploring his anger doesn’t take precedence over safeguarding
the client and staff.

Question 4
A female client with anorexia nervosa describes herself as “a whale.” However, the nurse’s
assessment reveals that the client is 5′ 8″ (1.7 m) tall and weighs only 90 lb (40.8 kg).
Considering the client’s unrealistic body image, which intervention should nurse Angel be
included in the plan of care?

Asking the client to compare her figure
with magazine photographs of women
her age

Assigning the client to group therapy in
which participants provide realistic
feedback about her weight

Option A is inappropriate because discussing the client’s perceptions and feeling wouldn’t help her to identify. making option B incorrect. Focusing discussions on food and weight would give the client attention for not eating.” Which strategy should the nurse use to deal with the client’s distorted perceptions and feelings? Avoid discussing the client’s perceptions and feelings Focus discussions on food and weight Avoid discussing unrealistic cultural standards regarding weight Provide objective data and feedback regarding the client’s weight and attractiveness Question 5 Explanation: By focusing on reality. accept. the client needs assistance with making decisions about health. who tell the admitting nurse that the client repeatedly drives while intoxicated despite their pleas to stop. Question 6 WRONG A male client is brought to the psychiatric clinic by family members. During . Instead of protecting the client’s health. “When I look in the mirror. options A. I look so fat and ugly. scheduled during each shift Telling the client of the nurse’s concern for her health and desire to help her make decisions to keep her healthy Question 4 Explanation: A client with anorexia nervosa has an unrealistic body image that causes consumption of little or no food. and C may serve to make the client defensive and more entrenched in her unrealistic body image. Therefore. this strategy may help the client develop a more realistic body image and gain self-esteem. Question 5 WRONG A 24-year old client with anorexia nervosa tells the nurse. and work through them. I hate what I see. Option C is inappropriate because recognizing unrealistic cultural standards wouldn’t help the client establish more realistic weight goals. Confronting the client about her actual appearance during one-on-one sessions. B.

” “I know I’ve been arrested three times for drinking and driving. while driving). criteria for this disorder include a need for increasing amounts of the substance to achieve intoxication (option A). and typical withdrawal interview with the nurse Linda. In fact. inability to fulfill role obligations (option C). Police suspect the client was intoxicated at the time of the accident. Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dl). For this client. occupational. 4th edition.” Question 6 Explanation: According to the Diagnostic and Statistical Manual of Mental Disorders. increased time and money spent on the substance (option B).” “I only spend half of my paycheck at the bar. or physical problem caused or exacerbated by substance abuse or recurrent use in dangerous situations (for example. psychoactive substance dependence must be ruled out. diagnostic criteria for psychoactive substance abuse include a maladaptive pattern of such use. the client periodically complains of tingling and numbness in the hands and feet. The client later admits to drinking heavily for years. but the police are just trying to hassle me. Nurse Gian realizes that these symptoms probably result from: acetate accumulation thiamine deficiency triglyceride buildup a below-normal serum potassium level Question 7 Explanation: .” “I just drink to relax after work. which statement by the client most strongly supports a diagnosis of psychoactive substance abuse? “I’m not addicted to alcohol. During hospitalization. psychological. Question 7 WRONG A male client is hospitalized with fractures of the right femur and right humerus sustained in a motorcycle accident. indicated either by continued use despite knowledge of having a persistent or recurrent social. I can drink more than I used to without being affected.

Based on this response. Initial nursing assessment reveals that the client’s wrists are scratched from a recent suicide attempt. Treatment includes reducing alcohol intake. nurse Lorena should expect early withdrawal symptoms to: begin after 7 days not occur at all because the time period for their occurrence has passed begin anytime within the next 1 to 2 days . The observation that the client has scratched wrists doesn’t substantiate the other options. correcting nutritional deficiencies through diet and vitamin supplements. which results from inadequate intake of vitamin B1 (thiamine) secondary to prolonged and excessive alcohol intake. especially of a physically self-destructive sort. Question 8 WRONG A female client with borderline personality disorder is admitted to the psychiatric unit. Acetate accumulation. As part of the intake interview. triglyceride buildup. the nurse asks him when he had his last alcoholic drink. the nurse Lenny should formulate a nursing diagnosis of: Ineffective individual coping related to feelings of guilt Situational low self-esteem related to feelings of loss of control Risk for violence: Self-directed related to impulsive mutilating acts Risk for violence: Directed toward others related to verbal threats Question 8 Explanation: The predominant behavioral characteristic of the client with borderline personality disorder is impulsiveness. Question 9 WRONG A male client is being admitted to the substance abuse unit for alcohol detoxification. He says that he had his last drink 6 hours before admission.Numbness and tingling in the hands and feet are symptoms of peripheral polyneuritis. Based on this finding. and a below-normal serum potassium level are unrelated to the client’s symptoms. and preventing such residual disabilities as foot and wrist drop.

or talks about wanting to die or attempting suicide is considered at a lower risk for suicide because this behavior typically serves to alert others that the client is contemplating suicide and wishes to be helped. jumping off a bridge. or hanging). a rifle hidden in the garage). A client who gives away possessions. has a specific plan (for example. by gunshot. Question 11 WRONG Which of the following drugs should Nurse Mary prepare to administer to a client with a toxic acetaminophen (Tylenol) level? deferoxamine mesylate (Desferal) succimer (Chemet) . Delirium tremens may occur 2 to 4 days — even up to 7 days — after the last drink. after the spouse leaves for work). Question 10 WRONG Nurse Amy is aware that the client is at highest risk for suicide? One who appears depressed. and has the means readily available (for example. and gives away all personal possessions One who plans a violent death and has the means readily available One who tells others that he or she might do something if life doesn’t get better soon One who talks about wanting to die Question 10 Explanation: The client at highest risk for suicide is one who plans a violent death (for example. frequently thinks of dying. thinks about death. begin within 2 to 7 days Question 9 Explanation: Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1 to 2 days later.

flumazenil (Romazicon) acetylcysteine (Mucomyst) Question 11 Explanation: The antidote for acetaminophen toxicity is acetylcysteine. Although bed rest is indicated. Question 13 WRONG A male client has approached the nurse asking for advice on how to deal with his alcohol addiction. Flumazenil reverses the sedative effects of benzodiazepines. To avoid overstimulating the client. Also. Succimer is an antidote for lead poisoning. It enhances conversion of toxic metabolites to nontoxic metabolites. restraints are unnecessary unless the client poses a danger to himself or others. Deferoxamine mesylate is the antidote for iron intoxication. Offering juice is appropriate. Nurse Joy is aware that the best nursing intervention at this time? Keeping the client restrained in bed Checking the client’s blood pressure every 15 minutes and offering juices Providing a quiet environment and administering medication as needed and prescribed Restraining the client and measuring blood pressure every 30 minutes Question 12 Explanation: Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment to reduce stimulation and administering prescribed central nervous system depressants in dosages that control symptoms without causing oversedation. Question 12 WRONG A female client begins to experience alcoholic hallucinosis. the nurse should check blood pressure every 2 hours. restraints may increase agitation and make the client feel trapped and helpless when hallucinating. Nurse Sally should tell the client that the only effective treatment for alcoholism is: Psychotherapy . but measuring blood pressure every 15 minutes would interrupt the client’s rest.

Surrounded by broken glass. Question 14 WRONG A male client is found sitting on the floor of the bathroom in the day treatment clinic with moderate lacerations on both wrists. the nurse should approach the client cautiously while calling her name and talking to her in a calm. she sits staring blankly at her bleeding wrists while staff members call for an ambulance. If the client shows signs of agitation or confusion or poses a threat. total abstinence Alcoholics Anonymous (AA) aversion therapy Question 13 Explanation: Total abstinence is the only effective treatment for alcoholism. Therefore. the nurse should observe the client’s response carefully. the nurse should retreat and request assistance. The nurse shouldn’t attempt to sit next to the client or examine injuries without first announcing the nurse’s presence and assessing the dangers of the situation. and telling her that the nurse is here to help her Question 14 Explanation: Ensuring the safety of the client and the nurse is the priority at this time. After explaining that the nurse is there to help. attendance at AA meetings. calling her name. confident manner. Psychotherapy. The nurse should keep in mind that the client shouldn’t be startled or overwhelmed. and aversion therapy are all adjunctive therapies that can support the client in his efforts to abstain. How should Nurse Anuktakanuk approach her initially? Enter the room quietly and move beside her to assess her injuries Call for staff back-up before entering the room and restraining her Move as much glass away from her as possible and sit next to her quietly Approach her slowly while speaking in a calm voice. Question 15 WRONG .

but she should keep a strict calorie count. the drug is more likely to cause tachyarrhythmias than bradyarrhythmias. and sudden death. Let the client eat her meals in private. The nurse concludes that the client is at high risk for which complication of cocaine use? Coronary artery spasm Bradyarrhythmias Neurobehavioral deficits Panic disorder Question 15 Explanation: Cocaine use may cause such cardiac complications as coronary artery spasm. epinephrine. Consequently. Which intervention is also important? Fill out the client’s menu and make sure she eats at least half of what is on her tray. myocardial infarction. Then engage her in social activities for at least 2 hours after each meal Let the client choose her own food. endocarditis. Question 16 Explanation: .A male client recently admitted to the hospital with sharp. Although neurobehavioral deficits are common in neonates born to cocaine users. On further questioning. dilated cardiomyopathy. not panic disorder Question 16 WRONG Nurse Mary is caring for a client with bulimia. Strict management of dietary intake is necessary. the client admits to having used cocaine recently after previously denying use of the drug. a person who’s addicted to cocaine typically experiences euphoria followed by depression. Nurse Ryan notes a rise in the client’s arterial blood pressure and a heart rate of 144 beats/minute. then stay with her for 1 hour after each meal Let the client eat food brought in by the family if she chooses. and dopamine. If she eats everything she orders. they are rare in adults. acute heart failure. substernal chest pain suddenly complains of palpitations. causing an excess of these neurotransmitters at postsynaptic receptor sites. Cocaine blocks reuptake of norepinephrine. As craving for the drug increases.

includes delinquency. Question 17 WRONG When interviewing the parents of an injured child. He dropped out of school at age 16 and has been living on his own since then. auto theft. If they change their story when different health care workers ask the same question. His history suggests maladaptive coping. She must then eat 100% of what she selected. Parents may argue and be demanding because of the stress of having an injured child. the emergency department nurse should be suspicious that child abuse is occurring. this is a clue that child abuse may be a problem. Child abuse occurs in all socioeconomic groups. Bulimic clients should only be allowed to eat food provided by the dietary department. and vandalism. which dates to his early teenage years. running away.Allowing the client to select her own food from the menu will help her feel some sense of control. which is associated with: antisocial personality disorder borderline personality disorder obsessive-compulsive personality disorder . which of the following is the strongest indicator that child abuse may be a problem? The injury isn’t consistent with the history or the child’s age The mother and father tell different stories regarding what happened The family is poor The parents are argumentative and demanding with emergency department personnel Question 17 Explanation: When the child’s injuries are inconsistent with the history given or impossible because of the child’s age and developmental stage. Question 18 WRONG Kevin is remanded by the courts for psychiatric treatment. Remaining with the client for at least 1 hour after eating will prevent purging. The parents may tell different stories because their perception may be different regarding what happened. His police record.

Question 19 WRONG Nurse Alice is caring for a client being treated for alcoholism. Question 20 WRONG A male client admitted to the psychiatric unit for treatment of substance abuse says to the nurse. Before initiating therapy with disulfiram (Antabuse). Narcissistic personality disorder is marked by a pattern of self-involvement. The client receiving disulfiram must be taught to read ingredient labels carefully to avoid products containing alcohol such as aftershave lotions. vandalism. I’m going to stop speaking to you. the client exhibits mood instability. In borderline personality disorder. This maladaptive coping pattern is manifested by a disregard for societal norms of behavior and an inability to relate meaningfully to others. the client experiences noxious and uncomfortable symptoms.” Which of the following is the most appropriate response? “If you continue to talk like that. Obsessive-compulsive personality disorder is characterized by a preoccupation with impulses and thoughts that the client realizes are senseless but can’t control. Disulfiram works by blocking the oxidation of alcohol. and dropping out of school are characteristic of antisocial personality disorder. identity disturbance. running away from home. the nurse teaches the client that he must read labels carefully on which of the following products? Carbonated beverages Aftershave lotion Toothpaste Cheese Question 19 Explanation: Disulfiram may be given to clients with chronic alcohol abuse who wish to curb impulse drinking. narcissistic personality disorder Question 18 Explanation: The client’s history of delinquency. toothpaste. “It felt so wonderful to get high.” . grandiosity. As acetaldehyde builds up in the blood. and cheese don’t contain alcohol and don’t need to be avoided by the client. Even alcohol rubbed onto the skin can produce a reaction. Carbonated beverages. and demand for constant attention. inhibiting the conversion of acetaldehyde to acetate. and labile affect. poor self-image.

disobedient. “You told me you got fired from your last job for missing too many days after taking drugs all night. Making threats (option A) isn’t an effective way to promote self-disclosure or establish a rapport with the client. an episode of substance abuse (option C). Question 21 WRONG The nurse is aware that the outcome criteria would be appropriate for a child diagnosed with oppositional defiant disorder? Accept responsibility for own behaviors Be able to verbalize own needs and assert rights Set firm and consistent limits with the client Allow the child to establish his own limits and boundaries Question 21 Explanation: Children with oppositional defiant disorder frequently violate the rights of others. Although the nurse should encourage the client to discuss feelings.” “Don’t you know it’s illegal to use drugs?” Question 20 Explanation: Confronting the client with the consequences of substance abuse helps to break through denial. Encouraging elaboration about his experience while getting high may reinforce the abusive behavior. not during. The client undoubtedly is aware that drug use is illegal. They are defiant. Options C and D aren’t outcome criteria but interventions.” “Tell me more about how it felt to get high. and blame others for their actions. Accountability for their actions would demonstrate progress for the oppositional child. Option B is incorrect as the oppositional child usually focuses on his own needs. the discussion should focus on how the client felt before. a reminder to this effect (option D) is unlikely to alter behavior. Question 22 .

7° C). WRONG Eighteen hours after undergoing an emergency appendectomy.6° F (38. but you’re just wasting your time. 101. Because their therapeutic relationships with caregivers are less important than their need to purge. 24 breaths/minute.” “How are you purging and when do you do it?” “Don’t worry. they wouldn’t cause this client’s signs and symptoms and typically would occur later in the postoperative course Question 23 WRONG During postprandial monitoring. 126 beats/minute. I won’t allow you to purge today.” What is the nurse’s best response? “I trust you not to purge. my goal is to do it twice. heart rate. Nurse Melinda should suspect: a postoperative infection alcohol withdrawal acute sepsis pneumonia Question 22 Explanation: The client’s vital signs and hallucinations suggest delirium tremens or alcohol withdrawal syndrome. respiratory rate. An . The client exhibits gross hand tremors and is screaming for someone to kill the bugs in the bed.” Question 23 Explanation: This response acknowledges that the client is testing limits and that the nurse is setting them by performing postprandial monitoring to prevent self-induced emesis. acute sepsis.” “I know it’s important for you to feel in control. they don’t fear betraying the nurse’s trust by engaging in the activity. After you sat with me yesterday. Clients with bulimia nervosa need to feel in control of the diet because they feel they lack control over all other aspects of their lives. I was still able to purge. Today. “You can sit with me. They commonly plot purging and rarely share their secrets about it. a client with a reported history of social drinking displays these vital signs: temperature. a female client with bulimia nervosa tells the nurse. and blood pressure. and pneumonia may arise as postoperative complications. but I’ll monitor you for 90 minutes after you eat. Although infection. 140/96 mm Hg.

which allegedly happened when the child fell down the stairs. The child pulls away from contact with the physician. Question 24 WRONG A parent brings a preschooler to the emergency department for treatment of a dislocated shoulder. What would be the most therapeutic response from nurse Julia? “Why didn’t you get someone else to drive you?” “Tell me how you feel about the accident.” .” “You should know better than to drink and drive. The child doesn’t cry when the shoulder is examined.authoritarian or challenging response may trigger a power struggle between the nurse and client. Question 24 Explanation: A characteristic behavior of abused children is lack of crying when they undergo a painful procedure or are examined by a health care professional. The child doesn’t make eye contact with the nurse.” “I recommend that you attend an Alcoholics Anonymous meeting. Which action should make the nurse suspect that the child was abused? The child cries uncontrollably throughout the examination. Crying throughout the examination. pulling away from the physician. and not making eye contact with the nurse are normal behaviors for preschoolers. Question 25 WRONG A male client tells the nurse he was involved in a car accident while he was intoxicated. Therefore. the nurse should suspect child abuse.

Nurse Lily should suggest that the family join which organization? Al-Anon Make Today Count Emotions Anonymous Alcoholics Anonymous Question 26 Explanation: Al-Anon is an organization that assists family members to share common experiences and increase their understanding of alcoholism. Emotions Anonymous is a support group for people experiencing depression. A judgmental approach isn’t therapeutic.Question 25 Explanation: An open-ended statement or question is the most therapeutic response. thus fostering dependency. After a family meeting. the client’s spouse asks the nurse about ways to help the family deal with the effects of alcoholism. Question 27 WRONG Nurse Tamara is caring for a client diagnosed with bulimia. the nurse suggests that the client isn’t capable of making decisions. anxiety. The most appropriate initial goal for a client diagnosed with bulimia is to: avoid shopping for large amounts of food control eating impulses identify anxiety-causing situations eat only three meals per day . It encourages the widest range of client responses. Asking the client why he drove while intoxicated can make him feel defensive and intimidated. Make Today Count is a support group for people with life-threatening or chronic illnesses. By giving advice. and shows the client that the nurse is interested in his feelings. makes the client an active participant in the conversation. or similar conditions. Alcoholics Anonymous is an organization that helps alcoholics recovers by using a twelve-step program. Question 26 WRONG A male client is being treated for alcoholism.

Question 28 WRONG A male client is admitted to the substance abuse unit for alcohol detoxification. or delirium. Which of the following goals is a priority? The client will commit to a drug-free lifestyle The client will work with the nurse to remain safe The client will drink plenty of fluids daily . Which of the following medications is Nurse Alice most likely to administer to reduce the symptoms of alcohol withdrawal? naloxone (Narcan) haloperidol (Haldol) magnesium sulfate chlordiazepoxide (Librium) Question 28 Explanation: Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of alcohol withdrawal. severe agitation. Haloperidol (Haldol) may be given to treat clients with psychosis. Managing eating impulses and replacing them with adaptive coping mechanisms can be integrated into the plan of care after initially addressing 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. Eating three meals per day isn’t a realistic goal early in treatment. Naloxone (Narcan) is administered for narcotic overdose. Controlling shopping for large amounts of food isn’t a goal early in treatment. Magnesium sulfate and other anticonvulsant medications are only administered to treat seizures if they occur during withdrawal.Question 27 Explanation: Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. Question 29 WRONG A 25 –year old client experiencing alcohol withdrawal is upset about going through detoxification.

but ensuring the client’s safety is the nurse’s top priority. Therefore. such responses set the overall mood for the nurse-client relationship. Referring the client to a clergyperson may increase the client’s trust or alleviate guilt. however. The client will make a personal inventory of strength Question 29 Explanation: The priority goal in alcohol withdrawal is maintaining the client’s safety. it isn’t the highest priority. What fact should the nurse remember to be typical of parents of clients with anorexia nervosa? They tend to overprotect their children . nurse Rose plans to include the parents in therapy sessions along with the client. beliefs. however. conducting such an assessment isn’t a nursing priority. Committing to a drug-free lifestyle. which is the nurse’s highest care priority? Assessing the client’s home environment and relationships outside the hospital Exploring the nurse’s own feelings about suicide Discussing the future with the client Referring the client to a clergyperson to discuss the moral implications of suicide Question 30 Explanation: The nurse’s values. Initially. and attitudes toward self-destructive behavior influence responses to a suicidal client. Question 31 WRONG For a female client with anorexia nervosa. and identifying personal strengths are important goals. Discussing the future and providing anticipatory guidance can help the client prepare for future stress. Assessment of the client’s home environment and relationships may reveal the need for family therapy. the nurse initially must explore personal feelings about suicide to avoid conveying negative feelings to the client. drinking plenty of fluids. Question 30 WRONG Nurse Mary is assigned to care for a suicidal client. but this isn’t a priority.

C. and D isn’t typical of parents of children with anorexia. These clients use eating to gain control of an aspect of their lives. Nurse Vic caring for her realizes that this exacerbation of anorexia nervosa results from the client’s effort to: manipulate her husband gain control of one part of her life commit suicide live up to her mother’s expectations Question 32 Explanation: By refusing to eat. Question 32 WRONG A client whose husband just left her has a recurrence of anorexia nervosa. worthlessness. a client with anorexia nervosa is unconsciously attempting to gain control over the only part of her life she feels she can control. by refusing to eat. and hopelessness. The client isn’t attempting to commit suicide through starvation. she is expressing feelings of despair. They usually have a history of substance abuse They maintain emotional distance from their children They alternate between loving and rejecting their children Question 31 Explanation: Clients with anorexia nervosa typically come from a family with parents who are controlling and overprotective. rather. This eating disorder doesn’t represent an attempt to manipulate others or live up to their expectations (although anorexia nervosa has a high incidence in families that emphasize achievement). Question 33 WRONG Flumazenil (Romazicon) has been ordered for a male client who has overdosed on oxazepam (Serax). nurse Gina should be prepared for which common adverse effect? . The characteristics described in options B. Before administering the medication.

The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine overdose. The reasons they stay in the relationship are complex and can be explored at a later time. Less common adverse effects include shivering. Question 34 WRONG Nurse Taylor is aware that the victims of domestic violence should be assessed for what important information? Reasons they stay in the abusive relationship (for example. and chest pain. Nurse Jimmy is aware that which goal takes the highest priority? . anxiety. The use of drugs or alcohol is irrelevant. lack of financial autonomy and isolation) Readiness to leave the perpetrator and knowledge of resources Use of drugs or alcohol History of previous victimization Question 34 Explanation: Victims of domestic violence must be assessed for their readiness to leave the perpetrator and their knowledge of the resources available to them. There is no evidence to suggest that previous victimization results in a person’s seeking or causing abusive relationships. Nurses can then provide the victims with information and options to enable them to leave when they are ready. Seizures Shivering Anxiety Chest pain Question 33 Explanation: Seizures are the most common serious adverse effect of using flumazenil to reverse benzodiazepine overdose. Question 35 WRONG For a female client with anorexia nervosa.

Because a client with anorexia nervosa eats little or nothing. Initially. self-perception (as in option C). The nurse may give lesser priority to goals that address long-term plans (as in option B). Question 36 WRONG Nurse Helen is assigned to care for a client with anorexia nervosa. and potential complications (as in option D). . all humans need to meet basic physiological needs first. Instead of giving the client unlimited time to eat. as in option D. Option C would reinforce control issues. the nurse must first plan to help the client meet this basic. the nurse should set limits and let the client know what is expected. which are central to this client’s underlying psychological problem. Option B wouldn’t be therapeutic because other clients may urge the client to eat and give attention for not eating. The client will establish adequate daily nutritional intake The client will make a contract with the nurse that sets a target weight The client will identify self-perceptions about body size as unrealistic The client will verbalize the possible physiological consequences of self- starvation Question 35 Explanation: According to Maslow’s hierarchy of needs. immediate physiological need. the nurse should provide one-on-one supervision during meals and for 1 hour afterward. which nursing intervention is most appropriate for this client? Providing one-on-one supervision during meals and for 1 hour afterward Letting the client eat with other clients to create a normal mealtime atmosphere Trying to persuade the client to eat and thus restore nutritional balance Giving the client as much time to eat as desired Question 36 Explanation: Because the client with anorexia nervosa may discard food or induce vomiting in the bathroom.

it isn’t the drug of choice in hypertension. To correct these problems. Lidocaine. Question 38 WRONG A female client who’s at high risk for suicide needs close supervision. an antiarrhythmic. Nurse Mary should: check the client frequently at irregular intervals throughout the night assure the client that the nurse will hold in confidence anything the client says repeatedly discuss previous suicide attempts with the client disregard decreased communication by the client because this is common in suicidal clients Question 38 Explanation: Checking the client frequently but at irregular intervals prevents the client from predicting when observation will take place and altering behavior in a misleading way at these times. to treat hypertension. the nurse expects the physician to prescribe: norepinephrine (Levophed) and lidocaine (Xylocaine) nifedipine (Procardia) and lidocaine nitroglycerin (Nitro-Bid IV) and esmolol (Brevibloc) nifedipine and esmolol Question 37 Explanation: This client requires a vasodilator. Decreased . Option B may encourage the client to try to manipulate the nurse or seek attention for having a secret suicide plan. Option C may reinforce suicidal ideas. such as nifedipine. isn’t indicated because the client doesn’t have an arrhythmia. and a beta- adrenergic blocker. such as esmolol. Although nitroglycerin may be used to treat coronary vasospasm. nurse Aaron notes sudden increases in the arterial blood pressure and heart rate. To best ensure the client’s safety.Question 37 WRONG When monitoring a female client recently admitted for treatment of cocaine addiction. to reduce the heart rate.

the physician is most likely to prescribe an infusion of nitroglycerin to dilate the coronary arteries. which will reduce her anxiety Question 39 Explanation: Establishing a consistent eating plan and monitoring the client’s weight are important for this disorder. the nurse shouldn’t disregard it (option D) Question 39 WRONG Nurse Harry is developing a plan of care for a client with anorexia nervosa.communication is a sign of withdrawal that may indicate the client has decided to commit suicide. Which action should the nurse include in the plan? Restrict visits with the family until the client begins to eat Provide privacy during meals Set up a strict eating plan for the client Encourage the client to exercise. Exercise must be limited and supervised. 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. Question 40 WRONG A male client with a history of cocaine addiction is admitted to the coronary care unit for evaluation of substernal chest pain. Lidocaine and procainamide are cardiac drugs that may be indicated for . To reverse this problem. nurse Greg expects the physician to prescribe: lidocaine (Xylocaine) procainamide (Pronestyl) nitroglycerin (Nitro-Bid IV) epinephrine Question 40 Explanation: The elevated ST segments in this client’s ECG indicate myocardial ischemia. The family should be included in the client’s care. The client should be monitored during meals — not given privacy.

hallucinations or delusions. profanity. However. inability to focus attention. Violent clients rarely exhibit depression. and somatic complaints. This client has a long history of initiating fights and abusing animals and recently was arrested for setting a neighbor’s dog on fire. paranoid ideas or suspicions. silence. Question 41 WRONG A male client is admitted to a psychiatric facility by court order for evaluation for antisocial personality disorder. noncompliance. clenched hands. restlessness. this drug must be used with caution because cocaine may potentiate its adrenergic effects. hostile threats. physical withdrawal. repetitive demands and complaints. inability to express feelings. nurse Perry should assess for which behavioral clues? A rigid posture. or hypervigilance. disorientation. argumentativeness. When evaluating this client for the potential for violence. a change in usual behavior. and glaring Depression and physical withdrawal Silence and noncompliance Hypervigilance and talk of past violent acts Question 41 Explanation: Behavioral clues that suggest the potential for violence include a rigid posture. restlessness.this client at some point but aren’t used for coronary artery dilation. recent alcohol ingestion or drug use. overreaction. glaring. talk of past violent acts. Question 42 WRONG Nurse Fey is aware that the drug of choice for treating Tourette syndrome? fluoxetine (Prozac) fluvoxamine (Luvox) haloperidol (Haldol) paroxetine (Paxil) Question 42 Explanation: . overtly aggressive actions. If a cocaine user experiences ventricular fibrillation or asystole. the physician may prescribe epinephrine.

Smith is most likely to prescribe which drug? clozapine (Clozaril) thiothixene (Navane) . Most clients with anorexia nervosa don’t like the way they look.Haloperidol is the drug of choice for treating Tourette syndrome. Preferring fast food over healthy food is common in this age-group. Prozac. A girl with cachexia may perceive herself to be overweight when she looks in the mirror. Dr. Nurse Kris conducts a health history interview. Constant dieting to get down to a “desirable weight” is characteristic of the disorder.” “I just can’t seem to get down to the weight I want to be. amenorrhea is common in a client with anorexia nervosa. Question 44 WRONG A male client who reportedly consumes 1 qt of vodka daily is admitted for alcohol detoxification. I’m so fat compared to other girls. otherwise.” “I don’t like the food my mother cooks.” Question 43 Explanation: Low self-esteem is the highest risk factor for anorexia nervosa. Because of the absence of body fat necessary for proper hormone production. To try to prevent alcohol withdrawal symptoms. I eat plenty of fast food when I’m out with my friends. I just need to keep my weight down because I’m a cheerleader. Which of the following comments indicates that the client may be suffering from anorexia nervosa? “I like the way I look. and Paxil are antidepressants and aren’t used to treat Tourette syndrome Question 43 WRONG A 14-year-old client is brought to the clinic by her mother.” “I do diet around my periods. Her mother expresses concern about her daughter’s weight loss and constant dieting. Luvox. I just get so bloated. Feeling inadequate when compared to peers indicates poor self-esteem. and their self-perception may be distorted.

and hypertension. lorazepam (Ativan) lithium carbonate (Eskalith) Question 44 Explanation: The best choice for preventing or treating alcohol withdrawal symptoms is lorazepam. a benzodiazepine. Question 45 WRONG Nurse Penny is aware that the following medical conditions is commonly found in clients with bulimia nervosa? Allergies Cancer Diabetes mellitus Hepatitis A Question 45 Explanation: Bulimia nervosa can lead to many complications. The eating disorder isn’t typically associated with allergies. cancer. including diabetes. and lithium carbonate is an antimanic agent. or hepatitis A. these drugs aren’t used to manage alcohol withdrawal syndrome. what would be the most desirable outcome? The student discusses conflicts over drug use The student accepts a referral to a substance abuse counselor The student agrees to inform his parents of the problem . Following the nurse’s assessment and interventions. a high school student is referred to the school nurse for suspected substance abuse. Question 46 WRONG Kellan. heart disease. Clozapine and thiothixene are antipsychotic agents.

however. Repeated slapping may indicate poor. and violence typically leads to further violence. the best outcome is that the student would agree to seek the assistance of a professional substance abuse counselor Question 47 WRONG Macoy and Helen seek emergency crisis intervention because he slapped her repeatedly the night before. impulse control. putting this couple at risk. When intervening with this couple. nurse Wayne is aware that the following is the highest priority? Client’s physical needs Client’s safety needs Client’s psychosocial needs . Violent people commonly are jealous and possessive and feel insecure in their relationships Question 48 WRONG When planning care for a client who has ingested phencyclidine (PCP). The husband indicates that his childhood was marred by an abusive relationship with his father. nurse Gerry knows they are at risk for repeated violence because the husband: has only moderate impulse control denies feelings of jealousy or possessiveness has learned violence as an acceptable behavior feels secure in his relationship with his wife Question 47 Explanation: Family violence usually is a learned behavior. The student reports increased comfort with making choice Question 46 Explanation: All of the outcomes stated are desirable. not moderate.

after the evening meal . Hypotension is associated with cardiovascular collapse and most commonly occurs in clients who don’t receive treatment. Drug effects are unpredictable and prolonged. psychosocial. fluctuating at different stages. a heart rate of 120 to 140 beats/minute. is a common sign of alcohol withdrawal. The nurse should monitor the client’s vital signs carefully throughout the entire alcohol withdrawal process. Question 49 WRONG Nurse Bella is aware that assessment finding is most consistent with early alcohol withdrawal? Heart rate of 120 to 140 beats/minute Heart rate of 50 to 60 beats/minute Blood pressure of 100/70 mm Hg Blood pressure of 140/80 mm Hg Question 49 Explanation: Tachycardia. may occur in later stages. Blood pressure may be labile throughout withdrawal. nurse Tair should plan to: severely restrict the client’s physical activities weigh the client daily. Question 50 WRONG A female client is admitted to the psychiatric clinic for treatment of anorexia nervosa. and the client may lose control easily. although rare during the early withdrawal stages. Hypotension. After safety needs have been met. To promote the client’s physical health. and medical needs can be met. Client’s medical needs Question 48 Explanation: The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as the staff. the client’s physical. Hypertension typically occurs in early withdrawal.

Therefore. the client may record food and fluid intake inaccurately. Option B is incorrect because a weight obtained after breakfast is more accurate than one obtained after the evening meal. infection. Option A may worsen anxiety. serum electrolyte levels. serum electrolyte level. hypothermia. monitoring the client’s vital signs. malnutrition. Option D would reward the client with attention for not eating and reinforce the control issues that are central to the underlying psychological problem. and acid base balance is crucial. . also. or cardiac abnormalities secondary to electrolyte imbalances. monitor vital signs. and acid-base balance instruct the client to keep an accurate record of food and fluid intake Question 50 Explanation: An anorexic client who requires hospitalization is in poor physical condition from starvation and may die as a result of arrhythmias.