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An unemployed woman, age 24, seeks help because she feels depressed and abandoned and doesn't know what to do with her life. She says she has quit her last five jobs because her coworkers didn't like her and didn't train her adequately. Last week, her boyfriend broke up with her after she drove his car into a tree after an argument. The client's initial diagnosis is borderline personality disorder. Which nursing observations support this diagnosis? A. Flat affect, social withdrawal, and unusual dress B. Suspiciousness, hypervigilance, and emotional coldness C. Lack of self-esteem, strong dependency needs, and impulsive behavior D. Insensitivity to others, sexual acting out, and violence Rationale: Borderline personality disorder is characterized by lack of self-esteem, strong dependency needs, and impulsive behavior. Instability in interpersonal relationships, mood, and poor self-image also is common. Typically, the client can't tolerate being alone and expresses feelings of emptiness or boredom. Flat affect, social withdrawal, and unusual dress are characteristic of schizoid personality disorder. Suspiciousness, hypervigilance, and emotional coldness are seen in paranoid personality disorders. In antisocial personality disorder, clients are usually insensitive to others and act out sexually; they may also be violent 2.In a toddler, which of the following injuries is most likely the result of child abuse? A. A hematoma on the occipital region of the head B. A 1-inch forehead laceration C. Several small, dime-sized circular burns on the child's back D. A small isolated bruise on the right lower extremity Rationale: Small circular burns on a child's back are no accident and may be from cigarettes. Toddlers are injury prone because of their developmental stage, and falls are frequent because of their unsteady gait; head injuries aren't uncommon. A small area of ecchymosis isn't suspicious in this age-group. 3. A client is admitted to the emergency department after being found unconscious. Her blood pressure is 82/50 mm Hg. She is 5′ 4" (1.6 m) tall, weighs 79 lb (35.8 kg), and appears dehydrated and emaciated. After regaining consciousness, she reports that she has had trouble eating lately and can't remember what she ate in the last 24 hours. She also states that she has had amenorrhea for the past year. She is convinced she is fat and refuses food. The nurse suspects that she has: A. bulimia nervosa. B. anorexia nervosa. C. depression.
D. schizophrenia. Rationale: Anorexia nervosa is an eating disorder characterized by self-imposed starvation with subsequent emaciation, nutritional deficiencies, and atrophic and metabolic changes. Typically, the client is hypotensive and dehydrated. Depending on the severity of the disorder, anorexic clients are at risk for circulatory collapse (indicated by hypotension), dehydration, and death. Bulimia nervosa is an eating disorder characterized by binge eating followed by self-induced vomiting. Although depression may be accompanied by weight loss, it isn't characterized by a body image disturbance or the intense fear of obesity seen in anorexia nervosa. Schizophrenia may cause bizarre eating patterns, but it rarely causes the full syndrome of anorexia nervosa. 4. A 15-year-old girl with anorexia has been admitted to a mental health unit. She refuses to eat. Which of the following statements is the best response from the nurse? A. "You don't have to eat. It's your choice." B. "I hope you'll eat your food by mouth. Tube feedings and I.V. lines can be uncomfortable." C. "Why do you think you're fat? You're underweight. Here — look in the mirror." D. "You really look terrible at this weight. I hope you'll eat." Rationale: Clients with anorexia can refuse food to the point of cardiac damage. Tube feedings and I.V. infusions are ordered to prevent such damage. The nurse is informing her of her treatment options. Option A doesn't tell the client about the consequences of choosing not to eat. Telling clients that they are too thin won't change their self-image. 5. A client with a history of substance abuse has been attending Alcoholics Anonymous meetings regularly in the psychiatric unit. One afternoon, the client tells the nurse, "I'm not going to those meetings anymore. I'm not like the rest of those people. I'm not a drunk. "What is the most appropriate response? A. "If you aren't an alcoholic, why do you keep drinking and ending up in the hospital?" B. "It's your decision. If you don't want to go, you don't have to." C. "You seem upset about the meetings." D. "You have to go to the meetings. It's part of your treatment plan." Rationale: The substance abuser uses the substance to cope with feelings and may deny the abuse. Asking if the client is upset about the meetings encourages the client to identify and deal with feelings instead of covering them up. Arguing with the client about the substance abuse (option A) or insisting that the client attend the meetings (option D) wouldn't help the client identify resistance to treatment. Option B isn't therapeutic behavior because it plays down the importance of attending meetings. 6. A client is admitted to the inpatient adolescent unit after being arrested for attempting to sell cocaine to an undercover police officer. The nurse plans to write a behavioral contract. To best promote compliance, the contract should be written:
A. abstractly. B. by the client alone. C. jointly by the client and nurse. D. jointly by the physician and nurse. Rationale: A contract written jointly by the client and nurse most successfully promotes cooperation and consistent behavior. The most effective contract — and the type least likely to allow for manipulation and misinterpretation — states the behavioral terms as concretely as possible. A contract written solely by the client may not be agreeable to staff members; one written by the physician and nurse may not be agreeable to the client. 7. During which phase of alcoholism is loss of control and physiologic dependence evident? A. Prealcoholic phase B. Early alcoholic phase C. Crucial phase D. Chronic phase Rationale: The crucial phase is marked by physical dependence. The prealcoholic phase is characterized by drinking to medicate feelings and for relief from stress. The early phase is characterized by sneaking drinks, blackouts, rapidly gulping drinks, and preoccupation with alcohol. The chronic phase is characterized by emotional and physical deterioration. 8. Which of the following is important when restraining a violent client? A. Have three staff members present, one for each side of the body and one for the head. B. Always tie restraints to side rails. C. Have an organized, efficient team approach after the decision is made to restrain the client. D. Secure restraints to the gurney with knots to prevent escape. Rationale: Emergency department personnel should use an organized, team approach when restraining violent clients so that no one is injured in the process. The leader, located at the client's head, should take charge; four staff members are required to hold and restrain the limbs. For safety reasons, restraints should be fastened to the bed frame instead of the side rails. For quick release, loops should be used instead of knots 9. A client who's actively hallucinating is brought to the hospital by friends. They say that the client used either lysergic acid diethylamide (LSD) or angel dust (phencyclidine [PCP]) at a concert. Which of the following common assessment findings indicates that the client may have ingested PCP? A. Dilated pupils
B. Nystagmus C. Paranoia D. Altered mood Rationale: Phencyclidine is an anesthetic with severe psychological effects. It blocks the reuptake of dopamine and directly affects the midbrain and thalamus. Nystagmus and ataxia are common physical findings of PCP use. Dilated pupils are evidence of LSD ingestion. Paranoia and altered mood occur with both PCP and LSD ingestion. 10. A severely dehydrated teenager admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. Her history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the last month. She is 5′ 7" (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention takes highest priority? A. Initiating caloric and nutritional therapy as ordered B. Instituting behavioral modification therapy as ordered C. Addressing the client's low self-esteem D. Regularly monitoring vital signs and weight Rationale: The client with anorexia nervosa is at risk for death from self-starvation. Therefore, initiating caloric and nutritional therapy takes highest priority. Behavioral modification (in which client privileges depend on weight gain) and psychoanalysis (which addresses the client's low self-esteem, guilt, anxiety, and feelings of hopelessness and depression) are important aspects of care but are secondary to stabilizing the client's physical condition. Monitoring vital signs and weight is important in evaluating nutritional therapy but doesn't take precedence over providing adequate caloric intake to ensure survival 11. A client tells the nurse that he is having suicidal thoughts every day. In conferring with the treatment team, the nurse should make which of the following recommendations? A. A no-suicide contract B. Weekly outpatient therapy C. A second psychiatric opinion D. Intensive inpatient treatment Rationale: Inpatient care is the best intervention for a client who is thinking about suicide every day. Implementing a no-suicide contract is an important strategy, but this client requires additional care. Weekly therapy wouldn't provide the intensity of care that this case warrants. Obtaining a second opinion would take time; this client requires immediate intervention. 12. Which of the following etiologic factors predispose a client to Tourette syndrome? A. No known etiology
B. Abnormalities in brain neurotransmitters, structural changes in basal ganglia and caudate nucleus, and genetics C. Abnormalities in the structure and function of the ventricles D. Environmental factors and birth-related trauma Rationale: The etiology of Tourette syndrome includes genetics, abnormalities in neurotransmission, and structural changes in the basal ganglia and caudate nucleus. The ventricles in the brain, environmental factors, and birth trauma aren't involved. 13. A client is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but he can control his use if he chooses. Which coping mechanism is he using? A. Withdrawal B. Logical thinking C. Repression D. Denial Rationale: Denial is an unconscious defense mechanism in which emotional conflict and anxiety are avoided by refusing to acknowledge feelings, desires, impulses, or external facts that are consciously intolerable. Withdrawal is a common response to stress, characterized by apathy. Logical thinking IS the ability to think rationally and make responsible decisions, which would lead the client to admitting the problem and seeking help. Repression is suppressing past events from the consciousness because of guilty association. 14. An 16-year-old boy is admitted to the facility after acting out his aggressions inappropriately at school. Predisposing factors to the expression of aggression include: A. violence on television. B. passive parents. C. an internal locus of control. D. a single-parent family Rationale: Violence on television has been correlated with an increase in aggressive behavior. Passive parents contribute to acting-out behaviors but not specifically to violence. An internal locus of control leads to a positive sense of self-esteem and isn't related to violence or aggression. There is no direct correlation between single-parent families and violence. 15. A client is brought to the emergency department after being beaten by her husband, a prominent attorney. The nurse caring for this client understands that: A. open boundaries are common in violent families. B. violence usually results from a power struggle. C. domestic violence and abuse span all socioeconomic classes.
D. violent behavior is a genetic trait passed from one generation to the next. Rationale: Domestic violence and abuse affect all socioeconomic classes. Closed boundaries and an imbalance of power, with one member having control over the others, are common in violent families. Although violent behavior may be passed from one generation to the next, it's a learned behavior, not a genetic trait. 16. On discharge after treatment for alcoholism, a client plans to take disulfiram (Antabuse) as prescribed. When teaching the client about this drug, the nurse emphasizes the need to: A. avoid all products containing alcohol. B. adhere to concomitant vitamin B therapy. C. return for monthly blood drug level monitoring. D. limit alcohol consumption to a moderate level. Rationale: To avoid severe adverse effects, the client taking disulfiram must strictly avoid alcohol and all products that contain alcohol. Vitamin B therapy and blood monitoring aren't necessary during disulfiram therapy. 17. During a private conversation, a client with borderline personality disorder asks the nurse to keep his secret and then displays multiple, self-inflicted, superficial lacerations on the forearms. What is the nurse's best response? A. "That's it! You're on suicide precautions." B. "I'm going to tell your physician. Do you want to tell me why you did that?" C. "Tell me what type of instrument you used. I'm concerned about infection." D. "The team needs to know when something important occurs in treatment. I need to tell the others, but let's talk about it first." Rationale: This response informs the client of the nurse's planned actions and allows time to discuss the client's actions. Options A and B put the client on the defensive and may lead to a power struggle. Option C ignores the psychological implications of the client's actions. 18. The nurse is providing care for a 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: A. barbiturates. B. amphetamines. C. methadone. D. benzodiazepines. Rationale: 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. Barbiturates, amphetamines, and benzodiazepines are highly addictive and would require detoxification treatment. 19. 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: A. dilated pupils and slurred speech. B. rapid speech and agitation. C. dilated pupils and agitation. D. euphoria and constricted pupils. Rationale: Assessment findings in a client abusing opiates include agitation, slurred speech, euphoria, and constricted pupils. 20. Which of the following signs should the nurse expect in a client with known amphetamine overdose? A. Hypotension B. Tachycardia C. Hot, dry skin D. Constricted pupils Rationale: Amphetamines are central nervous system stimulants. They cause sympathetic stimulation, including hypertension, tachycardia, vasoconstriction, and hyperthermia. Hot, dry skin is seen with anticholinergic agents such as jimsonweed. Pupils will be dilated, not constricted. 21. 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? A. Instituting seizure precautions, obtaining frequent vital signs, and recording fluid intake and output B. Checking the client's medical records for health history information C. Attempting to contact the client's family to obtain more information about the client D. Restricting fluids and leaving the client alone to "sleep off" the episode Rationale: 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. After taking all possible precautions, the nurse can begin seeking health history information and, as needed, modify the plan of care. Fluids are typically increased unless contraindicated by a preexisting medical condition.
22. Which nursing action is best when trying to diffuse a client's impending violent behavior? A. Helping the client identify and express feelings of anxiety and anger B. Involving the client in a quiet activity to divert attention C. Leaving the client alone until the client can talk about feelings D. Placing the client in seclusion Rationale: 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. Close interaction with the client in a quiet activity may place the nurse at risk for injury should the client suddenly become violent. An agitated and potentially violent client shouldn't be left alone or unsupervised because the danger of the client acting out is too great. 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. 23. The nurse is working with a client who abuses alcohol. Which of the following facts should the nurse communicate to the client? A. Abstinence is the basis for successful treatment. B. Attendance at Alcoholics Anonymous meetings every day will cure alcoholism. C. For treatment to be successful, family members must participate. D. An occasional social drink is acceptable behavior for the alcoholic Rationale: The foundation of any treatment for alcoholism is abstinence. Attendance at Alcoholics Anonymous is helpful to some individuals to maintain strict abstinence. Participation in treatment by the family is beneficial to both the client and the family but isn't essential. Abstinence requires refraining from social drinking. 24. Which psychosocial influence has been causally related to the development of aggressive behavior and conduct disorder? A. An overbearing mother B. Rejection by peers C. A history of schizophrenia in the family D. Low socioeconomic status Rationale: Studies indicate that children who are rejected by their peers are more likely to behave aggressively. Aggression and conduct disorder are represented in all socioeconomic groups. Schizophrenia and an overbearing mother haven't been associated with aggression or conduct disorder
25. 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? A. Denial B. Obsession C. Compensation D. Rationalization Rationale: 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. Obsession isn't a defense mechanism. In compensation, the client emphasizes positive attributes to compensate for negative ones. In rationalization, the client justifies behaviors by faulty logic. 26. 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 STsegment 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: A. lidocaine (Xylocaine). B. procainamide (Pronestyl). C. nitroglycerin (Nitro-Bid IV). D. epinephrine. Rationale: 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. Lidocaine and procainamide are cardiac drugs that may be indicated for this client at some point but aren't used for coronary artery dilation. 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. 27. 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? A. "I like the way I look. I just need to keep my weight down because I'm a cheerleader." B. "I don't like the food my mother cooks. I eat plenty of fast food when I'm out with my friends." C. "I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls." D. "I do diet around my periods; otherwise, I just get so bloated."
Rationale: 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. 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. Preferring fast food over healthy food is common in this age-group. Because of the absence of body fat necessary for proper hormone production, amenorrhea is common in a client with anorexia nervosa. 28. Which is the drug of choice for treating Tourette syndrome? A. fluoxetine (Prozac) B. fluvoxamine (Luvox) C. haloperidol (Haldol) D. paroxetine (Paxil) Rationale: Haloperidol is the drug of choice for treating Tourette syndrome. Prozac, Luvox, and Paxil are antidepressants and aren't used to treat Tourette syndrome 29. 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? A. "Why didn't you get someone else to drive you?" B. "Tell me how you feel about the accident." C. "You should know better than to drink and drive." D. "I recommend that you attend an Alcoholics Anonymous meeting." Rationale: 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. Asking the client why he drove while intoxicated can make him feel defensive and intimidated. A judgmental approach isn't therapeutic. By giving advice, the nurse suggests that the client isn't capable of making decisions, thus fostering dependency. 30. 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? A. Vomiting, diarrhea, and bradycardia B. Dehydration, temperature above 101° F (38.3° C), and pruritus C. Hypertension, diaphoresis, and seizures D. Diaphoresis, tremors, and nervousness Rationale: 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. 31. When monitoring a client recently admitted for treatment of cocaine addiction, the nurse notes sudden increases in the arterial blood pressure and heart rate. To correct these problems, the nurse expects the physician to prescribe: A. norepinephrine (Levophed) and lidocaine (Xylocaine). B. nifedipine (Procardia) and lidocaine. C. nitroglycerin (Nitro-Bid IV) and esmolol (Brevibloc). D. nifedipine and esmolol Rationale: This client requires a vasodilator, such as nifedipine, to treat hypertension, and a beta-adrenergic blocker, such as esmolol, to reduce the heart rate. Lidocaine, an antiarrhythmic, isn't indicated because the client doesn't have an arrhythmia. Although nitroglycerin may be used to treat coronary vasospasm, it isn't the drug of choice in hypertension. 32. A client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals is a priority? A. The client will commit to a drug-free lifestyle. B. The client will work with the nurse to remain safe. C. The client will drink plenty of fluids daily. D. The client will make a personal inventory of strengths Rationale: The priority goal in alcohol withdrawal is maintaining the client's safety. Committing to a drug-free lifestyle, drinking plenty of fluids, and identifying personal strengths are important goals, but ensuring the client's safety is the nurse's top priority. 33. A client is admitted to a psychiatric facility by court order for evaluation for antisocial personality disorder. This client has a long history of initiating fights and abusing animals and recently was arrested for setting a neighbor's dog on fire. When evaluating this client for the potential for violence, the nurse should assess for which behavioral clues? A. A rigid posture, restlessness, and glaring B. Depression and physical withdrawal C. Silence and noncompliance D. Hypervigilance and talk of past violent acts
Rationale: Behavioral clues that suggest the potential for violence include a rigid posture, restlessness, glaring, a change in usual behavior, clenched hands, overtly aggressive actions, physical withdrawal, noncompliance, overreaction, hostile threats, recent alcohol ingestion or drug use, talk of past violent acts, inability to express feelings, repetitive demands and complaints, argumentativeness, profanity, disorientation, inability to focus attention, hallucinations or delusions, paranoid ideas or suspicions, and somatic complaints. Violent clients rarely exhibit depression, silence, or hypervigilance. 34. A client is brought to the psychiatric clinic by family members, who tell the admitting nurse that the client repeatedly drives while intoxicated despite their pleas to stop. During an interview with the nurse, which statement by the client most strongly supports a diagnosis of psychoactive substance abuse? A. "I'm not addicted to alcohol. In fact, I can drink more than I used to without being affected." B. "I only spend half of my paycheck at the bar." C. "I just drink to relax after work." D. "I know I've been arrested three times for drinking and driving, but the police are just trying to hassle me." Rationale: According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, diagnostic criteria for psychoactive substance abuse include a maladaptive pattern of such use, indicated either by continued use despite knowledge of having a persistent or recurrent social, occupational, psychological, or physical problem caused or exacerbated by substance abuse or recurrent use in dangerous situations (for example, while driving). For this client, psychoactive substance dependence must be ruled out; criteria for this disorder include a need for increasing amounts of the substance to achieve intoxication (option A), increased time and money spent on the substance (option B), inability to fulfill role obligations (option C), and typical withdrawal symptoms. 35. A client with borderline personality disorder is admitted to the psychiatric unit. Initial nursing assessment reveals that the client's wrists are scratched from a recent suicide attempt. Based on this finding, the nurse should formulate a nursing diagnosis of: A. Ineffective individual coping related to feelings of guilt. B. Situational low self-esteem related to feelings of loss of control. C. Risk for violence: Self-directed related to impulsive mutilating acts. D. Risk for violence: Directed toward others related to verbal threats. Rationale: The predominant behavioral characteristic of the client with borderline personality disorder is impulsiveness, especially of a physically self-destructive sort. The observation that the client has scratched wrists doesn't substantiate the other options. 36. A client recently admitted to the hospital with sharp, substernal chest pain suddenly complains of palpitations. The nurse notes a rise in the client's arterial blood pressure and a heart rate of 144 beats/minute. On further questioning, the client admits to having used
cocaine recently after previously denying use of the drug. The nurse concludes that the client is at high risk for which complication of cocaine use? A. Coronary artery spasm B. Bradyarrhythmias C. Neurobehavioral deficits D. Panic disorder Rationale: Cocaine use may cause such cardiac complications as coronary artery spasm, myocardial infarction, dilated cardiomyopathy, acute heart failure, endocarditis, and sudden death. Cocaine blocks reuptake of norepinephrine, epinephrine, and dopamine, causing an excess of these neurotransmitters at postsynaptic receptor sites. Consequently, the drug is more likely to cause tachyarrhythmias than bradyarrhythmias. Although neurobehavioral deficits are common in neonates born to cocaine users, they are rare in adults. As craving for the drug increases, a person who's addicted to cocaine typically experiences euphoria followed by depression, not panic disorder. 37. A client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink 6 hours before admission. Based on this response, the nurse should expect early withdrawal symptoms to: A. begin after 7 days. B. not occur at all because the time period for their occurrence has passed. C. begin anytime within the next 1 to 2 days. D. begin within 2 to 7 days. Rationale: Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1 to 2 days later. Delirium tremens may occur 2 to 4 days — even up to 7 days — after the last drink. 38. The nurse is assigned to care for a client with anorexia nervosa. Initially, which nursing intervention is most appropriate for this client? A. Providing one-on-one supervision during meals and for 1 hour afterward B. Letting the client eat with other clients to create a normal mealtime atmosphere C. Trying to persuade the client to eat and thus restore nutritional balance D. Giving the client as much time to eat as desired Rationale: Because the client with anorexia nervosa may discard food or induce vomiting in the bathroom, the nurse should provide one-on-one supervision during meals and for 1 hour afterward. Option B wouldn't be therapeutic because other clients may urge the client to eat and give attention for not eating. Option C would reinforce control issues, which are central to this client's underlying psychological problem. Instead of giving the client unlimited time to eat, as in option D, the nurse should set limits and let the client know what is expected.
39. A client begins to experience alcoholic hallucinosis. What is the best nursing intervention at this time? A. Keeping the client restrained in bed B. Checking the client's blood pressure every 15 minutes and offering juices C. Providing a quiet environment and administering medication as needed and prescribed D. Restraining the client and measuring blood pressure every 30 minutes Rationale: 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. Although bed rest is indicated, restraints are unnecessary unless the client poses a danger to himself or others. Also, restraints may increase agitation and make the client feel trapped and helpless when hallucinating. Offering juice is appropriate, but measuring blood pressure every 15 minutes would interrupt the client's rest. To avoid overstimulating the client, the nurse should check blood pressure every 2 hours. 40. Which assessment finding is most consistent with early alcohol withdrawal? A. Heart rate of 120 to 140 beats/minute B. Heart rate of 50 to 60 beats/minute C. Blood pressure of 100/70 mm Hg D. Blood pressure of 140/80 mm Hg Rationale: Tachycardia, a heart rate of 120 to 140 beats/minute, is a common sign of alcohol withdrawal. Blood pressure may be labile throughout withdrawal, fluctuating at different stages. Hypertension typically occurs in early withdrawal. Hypotension, although rare during the early withdrawal stages, may occur in later stages. Hypotension is associated with cardiovascular collapse and most commonly occurs in clients who don't receive treatment. The nurse should monitor the client's vital signs carefully throughout the entire alcohol withdrawal process. 41. Which client is at highest risk for suicide? A. One who appears depressed, frequently thinks of dying, and gives away all personal possessions B. One who plans a violent death and has the means readily available C. One who tells others that he or she might do something if life doesn't get better soon D. One who talks about wanting to die Rationale: The client at highest risk for suicide is one who plans a violent death (for example, by gunshot, jumping off a bridge, or hanging), has a specific plan (for example, after the spouse leaves for work), and has the means readily available (for example, a rifle hidden in the garage). A client who gives away possessions, thinks about death, 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. 42. Which of the following medical conditions is commonly found in clients with bulimia nervosa? A. Allergies B. Cancer C. Diabetes mellitus D. Hepatitis A Rationale: Bulimia nervosa can lead to many complications, including diabetes, heart disease, and hypertension. The eating disorder isn't typically associated with allergies, cancer, or hepatitis A. 43. A high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and interventions, what would be the most desirable outcome? A. The student discusses conflicts over drug use. B. The student accepts a referral to a substance abuse counselor. C. The student agrees to inform his parents of the problem. D. The student reports increased comfort with making choices. Rationale: All of the outcomes stated are desirable; however, the best outcome is that the student would agree to seek the assistance of a professional substance abuse counselor. 44. A client who reportedly consumes 1 qt of vodka daily is admitted for alcohol detoxification. To try to prevent alcohol withdrawal symptoms, the physician is most likely to prescribe which drug? A. clozapine (Clozaril) B. thiothixene (Navane) C. lorazepam (Ativan) D. lithium carbonate (Eskalith) Rationale: The best choice for preventing or treating alcohol withdrawal symptoms is lorazepam, a benzodiazepine. Clozapine and thiothixene are antipsychotic agents, and lithium carbonate is an antimanic agent; these drugs aren't used to manage alcohol withdrawal syndrome. 45. A client is being treated for alcoholism. After a family meeting, the client's spouse asks the nurse about ways to help the family deal with the effects of alcoholism. The nurse should suggest that the family join which organization? A. Al-Anon
B. Make Today Count C. Emotions Anonymous D. Alcoholics Anonymous Rationale: Al-Anon is an organization that assists family members to share common experiences and increase their understanding of alcoholism. Make Today Count is a support group for people with life-threatening or chronic illnesses. Emotions Anonymous is a support group for people experiencing depression, anxiety, or similar conditions. Alcoholics Anonymous is an organization that helps alcoholics recover by using a twelve-step program. 46. A client is admitted to the psychiatric clinic for treatment of anorexia nervosa. To promote the client's physical health, the nurse should plan to: A. severely restrict the client's physical activities. B. weigh the client daily, after the evening meal. C. monitor vital signs, serum electrolyte levels, and acid-base balance. D. instruct the client to keep an accurate record of food and fluid intake. Rationale: An anorexic client who requires hospitalization is in poor physical condition from starvation and may die as a result of arrhythmias, hypothermia, malnutrition, infection, or cardiac abnormalities secondary to electrolyte imbalances. Therefore, monitoring the client's vital signs, serum electrolyte level, and acid base balance is crucial. Option A may worsen anxiety. Option B is incorrect because a weight obtained after breakfast is more accurate than one obtained after the evening meal. Option D would reward the client with attention for not eating and reinforce the control issues that are central to the underlying psychological problem; also, the client may record food and fluid intake inaccurately. 47. A young man is remanded by the courts for psychiatric treatment. His police record, which dates to his early teenage years, includes delinquency, running away, auto theft, and vandalism. He dropped out of school at age 16 and has been living on his own since then. His history suggests maladaptive coping, which is associated with: A. antisocial personality disorder. B. borderline personality disorder. C. obsessive-compulsive personality disorder. D. narcissistic personality disorder. Rationale: The client's history of delinquency, running away from home, vandalism, and dropping out of school are characteristic of antisocial personality disorder. This maladaptive coping pattern is manifested by a disregard for societal norms of behavior and an inability to relate meaningfully to others. In borderline personality disorder, the client exhibits mood instability, poor self-image, identity disturbance, and labile affect. Obsessive-compulsive personality disorder is characterized by a preoccupation with impulses and thoughts that the client realizes are senseless but can't control. Narcissistic
personality disorder is marked by a pattern of self-involvement, grandiosity, and demand for constant attention. 48. A husband and wife seek emergency crisis intervention because he slapped her repeatedly the night before. The husband indicates that his childhood was marred by an abusive relationship with his father. When intervening with this couple, the nurse knows they are at risk for repeated violence because the husband: A. has only moderate impulse control. B. denies feelings of jealousy or possessiveness. C. has learned violence as an acceptable behavior. D. feels secure in his relationship with his wife. Rationale: Family violence usually is a learned behavior, and violence typically leads to further violence, putting this couple at risk. Repeated slapping may indicate poor, not moderate, impulse control. Violent people commonly are jealous and possessive and feel insecure in their relationships. 49. A client whose husband just left her has a recurrence of anorexia nervosa. The nurse caring for her realizes that this exacerbation of anorexia nervosa results from the client's effort to: A. manipulate her husband. B. gain control of one part of her life. C. commit suicide. D. live up to her mother's expectations. Rationale: By refusing to eat, a client with anorexia nervosa is unconsciously attempting to gain control over the only part of her life she feels she can control. 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). The client isn't attempting to commit suicide through starvation; rather, by refusing to eat, she is expressing feelings of despair, worthlessness, and hopelessness. 50. A client has approached the nurse asking for advice on how to deal with his alcohol addiction. The nurse should tell the client that the only effective treatment for alcoholism is: A. psychotherapy. B. total abstinence. C. Alcoholics Anonymous (AA). D. aversion therapy. Rationale: Total abstinence is the only effective treatment for alcoholism. Psychotherapy, attendance at AA meetings, and aversion therapy are all adjunctive therapies that can support the client in his efforts to abstain.
51. Flumazenil (Romazicon) has been ordered for a client who has overdosed on oxazepam (Serax). Before administering the medication, the nurse should be prepared for which common adverse effect? A. Seizures B. Shivering C. Anxiety D. Chest pain Rationale: Seizures are the most common serious adverse effect of using flumazenil to reverse benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine overdose. Less common adverse effects include shivering, anxiety, and chest pain. 52. The nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to: A. avoid shopping for large amounts of food. B. control eating impulses. C. identify anxiety-causing situations. D. eat only three meals per day. Rationale: 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. Controlling shopping for large amounts of food isn't a goal early in treatment. 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. Eating three meals per day isn't a realistic goal early in treatment. 53. A client who's at high risk for suicide needs close supervision. To best ensure the client's safety, the nurse should: A. check the client frequently at irregular intervals throughout the night. B. assure the client that the nurse will hold in confidence anything the client says. C. repeatedly discuss previous suicide attempts with the client. D. disregard decreased communication by the client because this is common in suicidal clients. Rationale: 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. 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. Decreased communication is a sign of withdrawal that may indicate the client has decided to commit suicide; the nurse shouldn't disregard it (option D
54. Which of the following drugs should the nurse prepare to administer to a client with a toxic acetaminophen (Tylenol) level? A. deferoxamine mesylate (Desferal) B. succimer (Chemet) C. flumazenil (Romazicon) D. acetylcysteine (Mucomyst) Rationale: The antidote for acetaminophen toxicity is acetylcysteine. It enhances conversion of toxic metabolites to nontoxic metabolites. Deferoxamine mesylate is the antidote for iron intoxication. Succimer is an antidote for lead poisoning. Flumazenil reverses the sedative effects of benzodiazepines. 55. A client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is the nurse most likely to administer to reduce the symptoms of alcohol withdrawal? A. naloxone (Narcan) B. haloperidol (Haldol) C. magnesium sulfate D. chlordiazepoxide (Librium) Rationale: Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of alcohol withdrawal. Haloperidol (Haldol) may be given to treat clients with psychosis, severe agitation, or delirium. Naloxone (Narcan) is administered for narcotic overdose. Magnesium sulfate and other anticonvulsant medications are only administered to treat seizures if they occur during withdrawal. 56. During postprandial monitoring, a client with bulimia nervosa tells the nurse, "You can sit with me, but you're just wasting your time. After you sat with me yesterday, I was still able to purge. Today, my goal is to do it twice." What is the nurse's best response? A. "I trust you not to purge." B. "How are you purging and when do you do it?" C. "Don't worry. I won't allow you to purge today." D. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat." Rationale: 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. 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. Because their therapeutic relationships with caregivers are less important than their need to purge, they don't fear betraying the nurse's trust by engaging in the activity. They commonly plot purging and rarely share their secrets about it. An authoritarian or challenging response may trigger a power struggle between the nurse and client.
57. A client admitted to the psychiatric unit for treatment of substance abuse says to the nurse, "It felt so wonderful to get high." Which of the following is the most appropriate response? A. "If you continue to talk like that, I'm going to stop speaking to you." B. "You told me you got fired from your last job for missing too many days after taking drugs all night." C. "Tell me more about how it felt to get high." D. "Don't you know it's illegal to use drugs?" Rationale: Confronting the client with the consequences of substance abuse helps to break through denial. Making threats (option A) isn't an effective way to promote selfdisclosure or establish a rapport with the client. Although the nurse should encourage the client to discuss feelings, the discussion should focus on how the client felt before, not during, an episode of substance abuse (option C). Encouraging elaboration about his experience while getting high may reinforce the abusive behavior. The client undoubtedly is aware that drug use is illegal; a reminder to this effect (option D) is unlikely to alter behavior. 58. For a client with anorexia nervosa, which goal takes the highest priority? A. The client will establish adequate daily nutritional intake. B. The client will make a contract with the nurse that sets a target weight. C. The client will identify self-perceptions about body size as unrealistic. D. The client will verbalize the possible physiological consequences of self-starvation. Rationale: According to Maslow's hierarchy of needs, all humans need to meet basic physiological needs first. Because a client with anorexia nervosa eats little or nothing, the nurse must first plan to help the client meet this basic, immediate physiological need. The nurse may give lesser priority to goals that address long-term plans (as in option B), selfperception (as in option C), and potential complications (as in option D). 59. When interviewing the parents of an injured child, which of the following is the strongest indicator that child abuse may be a problem? A. The injury isn't consistent with the history or the child's age. B. The mother and father tell different stories regarding what happened. C. The family is poor. D. The parents are argumentative and demanding with emergency department personnel. Rationale: When the child's injuries are inconsistent with the history given or impossible because of the child's age and developmental stage, the emergency department nurse should be suspicious that child abuse is occurring. The parents may tell different stories because their perception may be different regarding what happened. If they change their story when different health care workers ask the same question, this is a clue that child
abuse may be a problem. Child abuse occurs in all socioeconomic groups. Parents may argue and be demanding because of the stress of having an injured child. 60. For a client with anorexia nervosa, the nurse plans to include the parents in therapy sessions along with the client. What fact should the nurse remember to be typical of parents of clients with anorexia nervosa? A. They tend to overprotect their children. B. They usually have a history of substance abuse. C. They maintain emotional distance from their children. D. They alternate between loving and rejecting their children. Rationale: Clients with anorexia nervosa typically come from a family with parents who are controlling and overprotective. These clients use eating to gain control of an aspect of their lives. The characteristics described in options B, C, and D aren't typical of parents of children with anorexia. 61. 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? A. Remaining with the client and staying calm B. Calling a security guard and another staff member for assistance C. Telling the client's husband that he must leave at once D. Determining why the husband feels so angry Rationale: 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. 62. The nurse is caring for a client with bulimia. Strict management of dietary intake is necessary. Which intervention is also important? A. Fill out the client's menu and make sure she eats at least half of what is on her tray. B. Let the client eat her meals in private. Then engage her in social activities for at least 2 hours after each meal. C. Let the client choose her own food. If she eats everything she orders, then stay with her for 1 hour after each meal.
D. Let the client eat food brought in by the family if she chooses, but she should keep a strict calorie count. Rationale: Allowing the client to select her own food from the menu will help her feel some sense of control. She must then eat 100% of what she selected. Remaining with the client for at least 1 hour after eating will prevent purging. Bulimic clients should only be allowed to eat food provided by the dietary department. 63. The nurse is assigned to care for a suicidal client. Initially, which is the nurse's highest care priority? A. Assessing the client's home environment and relationships outside the hospital B. Exploring the nurse's own feelings about suicide C. Discussing the future with the client D. Referring the client to a clergyperson to discuss the moral implications of suicide Rationale: The nurse's values, beliefs, and attitudes toward self-destructive behavior influence responses to a suicidal client; such responses set the overall mood for the nurseclient relationship. Therefore, the nurse initially must explore personal feelings about suicide to avoid conveying negative feelings to the client. Assessment of the client's home environment and relationships may reveal the need for family therapy; however, conducting such an assessment isn't a nursing priority. Discussing the future and providing anticipatory guidance can help the client prepare for future stress, but this isn't a priority. Referring the client to a clergyperson may increase the client's trust or alleviate guilt; however, it isn't the highest priority. 64. A client with anorexia nervosa tells the nurse, "When I look in the mirror, I hate what I see. I look so fat and ugly." Which strategy should the nurse use to deal with the client's distorted perceptions and feelings? A. Avoid discussing the client's perceptions and feelings. B. Focus discussions on food and weight. C. Avoid discussing unrealistic cultural standards regarding weight. D. Provide objective data and feedback regarding the client's weight and attractiveness. Rationale: By focusing on reality, this strategy may help the client develop a more realistic body image and gain self-esteem. Option A is inappropriate because discussing the client's perceptions and feeling wouldn't help her to identify, accept, and work through them. Focusing discussions on food and weight would give the client attention for not eating, making option B incorrect. Option C is inappropriate because recognizing unrealistic cultural standards wouldn't help the client establish more realistic weight goals. 65. The nurse is caring for a client being treated for alcoholism. Before initiating therapy with disulfiram (Antabuse), the nurse teaches the client that he must read labels carefully on which of the following products?
A. Carbonated beverages B. Aftershave lotion C. Toothpaste D. Cheese Rationale: Disulfiram may be given to clients with chronic alcohol abuse who wish to curb impulse drinking. Disulfiram works by blocking the oxidation of alcohol, inhibiting the conversion of acetaldehyde to acetate. As acetaldehyde builds up in the blood, the client experiences noxious and uncomfortable symptoms. Even alcohol rubbed onto the skin can produce a reaction. The client receiving disulfiram must be taught to read ingredient labels carefully to avoid products containing alcohol such as aftershave lotions. Carbonated beverages, toothpaste, and cheese don't contain alcohol and don't need to be avoided by the client. 66. The nurse is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan? A. Restrict visits with the family until the client begins to eat. B. Provide privacy during meals. C. Set up a strict eating plan for the client. D. Encourage the client to exercise, which will reduce her anxiety. Rationale: Establishing a consistent eating plan and monitoring the client's weight are important for this disorder. The family should be included in the client's care. The client should be monitored during meals — not given privacy. Exercise must be limited and supervised. 67. Victims of domestic violence should be assessed for what important information? A. Reasons they stay in the abusive relationship (for example, lack of financial autonomy and isolation) B. Readiness to leave the perpetrator and knowledge of resources C. Use of drugs or alcohol D. History of previous victimization Rationale: Victims of domestic violence must be assessed for their readiness to leave the perpetrator and their knowledge of the resources available to them. Nurses can then provide the victims with information and options to enable them to leave when they are ready. The reasons they stay in the relationship are complex and can be explored at a later time. The use of drugs or alcohol is irrelevant. There is no evidence to suggest that previous victimization results in a person's seeking or causing abusive relationships. 68. A client is hospitalized with fractures of the right femur and right humerus sustained in a motorcycle accident. 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). The client
later admits to drinking heavily for years. During hospitalization, the client periodically complains of tingling and numbness in the hands and feet. The nurse realizes that these symptoms probably result from: A. acetate accumulation. B. thiamine deficiency. C. triglyceride buildup. D. a below-normal serum potassium level Rationale: Numbness and tingling in the hands and feet are symptoms of peripheral polyneuritis, which results from inadequate intake of vitamin B1 (thiamine) secondary to prolonged and excessive alcohol intake. Treatment includes reducing alcohol intake, correcting nutritional deficiencies through diet and vitamin supplements, and preventing such residual disabilities as foot and wrist drop. Acetate accumulation, triglyceride buildup, and a below-normal serum potassium level are unrelated to the client's symptoms. 69. A parent brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stairs. Which action should make the nurse suspect that the child was abused? A. The child cries uncontrollably throughout the examination. B. The child pulls away from contact with the physician. C. The child doesn't cry when the shoulder is examined. D. The child doesn't make eye contact with the nurse. Rationale: A characteristic behavior of abused children is lack of crying when they undergo a painful procedure or are examined by a health care professional. Therefore, the nurse should suspect child abuse. Crying throughout the examination, pulling away from the physician, and not making eye contact with the nurse are normal behaviors for preschoolers. 70. When planning care for a client who has ingested phencyclidine (PCP), which of the following is the highest priority? A. Client's physical needs B. Client's safety needs
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