A 15-year-old is admitted to an adolescent unit for evaluation. The adolescent has a long history of drug abuse, stealing, refusal to comply with rules, and an inability to get along in any setting. When collecting data related to the adolescent's lifestyle, the nurse may be prevented from accurately listening to what the client is saying by:
A personal cultural belief
The client's disease process
The pressure of time to complete care
A personal need to secure information
Before effectively responding to a sexually abused victim on the phone, it is essential that the nurse in the rape crisis center:
Get the client's full name and address
Call for assistance from the psychiatrist
Know some myths and facts about sexual assault
Be aware of any personal bias about sexual assault
A pregnant client, who has type 2 diabetes and a history of three miscarriages, is scheduled for a contraction stress test. Before the test she begins to cry when answering the nurse's questions about her previous pregnancies. She states, "I know it's my diabetes. This baby will never live. It's all my fault." The nurse's best response should be:
"I understand that this must be very stressful for you."
"Diabetes is a difficult disease to manage during pregnancy."
"This baby will live because it is being very closely monitored."
"I know you're worried, although getting upset can alter test findings."
A client with an inoperable temporal lobe tumor has been experiencing frightening audio hallucinations, especially when alone. The nurse can best help the client cope with these hallucinations by planning to:
Move the client to a four-bed room closer to the nurse's station
Suggest that the client turn on the radio or television when alone
Work out a schedule for visitors so that the client will not be alone
Have family or friends remain with the client until hallucinations stop
An older female client, who is confused and often does not recognize her children, is admitted to a nursing home. The client appears slovenly in attire, often soiling her clothing with feces and urine. The nurse can best manage this problem by:
Putting the client in orientation therapy
Toileting the client once every two hours
Supervising the client's bathroom activities closely
Explaining to the client how offensive her behavior is to others
The nurse is aware that the signs and symptoms that are most specific for diagnosing anorexia nervosa are:
Slow pulse, mild weight loss, and alopecia
Compulsive behaviors, excessive fears, and nausea
Excessive activity, memory lapses, and an increased pulse
Excessive weight loss, amenorrhea, and abdominal distention
The nursing intervention that should receive the highest priority in the period immediately following an emaciated 13-year-old's admission to the hospital for starvation secondary to anorexia nervosa is:
Providing adequate rest and nutrition
Correcting the client's fluid and electrolyte imbalances
Obtaining more data about the client's diet and exercise program
Completing an assessment of the client's physical and mental status
The nurse is aware that the major health complication associated with intractable anorexia nervosa is:
Endocrine imbalance, causing amenorrhea
Decreased metabolism, causing cold intolerance
Cardiac dysrhythmias, resulting in cardiac arrest
Glucose intolerance, resulting in protracted hypoglycemia
The multidisciplinary team decides to employ a behavior modification approach to a young female's problem with anorexia nervosa. A planned nursing intervention that would follow this approach is to:
Have the client role-play interactions with her parents
Provide the client with a high-calorie, high-protein diet
Restrict the client to her room until she gains 2 pounds
Force the client to talk about her favorite foods for 1 hour a day
When an adolescent female client with the diagnosis of anorexia nervosa starts to discuss food and eating, the nurse should plan to:
Use her current interest in food to encourage her to increase her intake
Tell her gently but firmly to direct her discussion of food to the nutritionist
Listen closely to determine her favorite foods and secure these foods for her
Let her talk about food as long as she wants and limit discussion about her eating
When developing an initial plan of care for a female client with a bipolar I disorder (manic episode) the nurse should plan to:
Increase her gym time
Isolate her from her peers
Provide food, fluids, and rest
Encourage her active participation in unit programs
A male client with cyclothymic disorder with hypomanic symptoms is admitted to the psychiatric unit. He has progressively lost weight and does not take the time to eat his food. The nurse can best respond to this situation by:
Providing a tray for him in his room
Assuring him that he is deserving of food
Pointing out that the energy he is burning up must be replaced
Ordering food that he can hold in his hand to eat while moving around
A client with a diagnosis of bipolar disorder with rapid cycling is readmitted 4 months after discharge. The client has become increasingly hyperverbal, loud, and intrusive. The most therapeutic response by the nurse who had cared for the client during the previous hospitalization is:
"Tell me about the medicine you take."
"You seem to have a need to interrupt me."
"How is your relationship with your spouse?"
"Do you feel that you are under great stress?"
Within a few hours of alcohol withdrawal, the nurse should assess a client for the presence of:
Irritability and tremors
Yawning and convulsions
Disorientation and paranoia
Fever and profuse diaphoresis
The nurse is planning care for a client who is an alcoholic. The nurse must be aware that the most serious, life-threatening symptoms from alcohol withdrawal usually occur how many hours after the last drink?
8 to 12
12 to 24
24 to 72
72 to 96
When a recently hospitalized client has a tentative diagnosis of opiate addiction, the nurse should assess the client for adaptations related to opiate withdrawal. These adaptations include:
Drowsiness
Hypotension
Pupillary dilation
Muscle twitching
After a binge with cocaine, the individual is found unconscious and is admitted to the hospital with acute cocaine toxicity. Initial nursing action should be directed toward:
Being understanding
Maintaining a drug-free environment
Providing the necessary physical care
Establishing a therapeutic relationship
After a visit from several friends the nurse finds a client with a known history of opiate addiction in a deep sleep and unresponsive to attempts at arousal. The nurse assesses the client's vital signs and determines that an overdose of opiates occurred if the findings showed a blood pressure of:
70/40 mm Hg, a pulse of 120, and respirations of 10
120/80 mm Hg, a pulse of 84, and respirations of 20
140/90 mm Hg, a pulse of 76, and respirations of 28
180/100 mm Hg, a pulse of 72, and respirations of 18
The nurse should know that the most common side effects of regular cocaine use include:
Nausea, fatigue, and extreme hunger
Anxiety, dysphoria, and suspiciousness
Seizures, hoarseness, and electrolyte imbalance
Lethargy, sexual arousal, and hormone imbalance
A client with a known history of opiate addiction is treated for multiple stab wounds to the abdomen. After surgical repair the nurse notes that the client's pain is not relieved by the prescribed morphine injections. The nurse recognizes that the failure to achieve pain relief from the morphine injections indicates that the client is probably experiencing the phenomenon of:
Tolerance
Habituation
Physical addiction
Psychologic addiction
During a family meeting a client with a substance abuse disorder accuses his wife of contributing to his substance abuse. The nurse evaluates that the psychoeducation the client and family received was ineffective because the client is:
Confronting his wife about her lack of support
Verbalizing negative feelings toward a family member
Having difficulty recalling that a change in one person affects the entire family
Creating an environment in which family members cannot learn about his problem
A client with a long history of alcohol abuse is placed on a diet high in vitamin B1 (thiamine). The nurse evaluates that the diet is understood when the client states, "I will select something for each meal from among:
Fish, aged cheese, and breads."
Poultry, milk products, and eggs."
Lean pork, organ meat, and nuts."
Leafy and green vegetables and citrus fruits."
A client being admitted for alcoholism reports having had alcoholic blackouts in the past. The nurse recognizes that an alcoholic blackout is best described as:
Fainting spells followed by loss of memory
A fugue state resembling absence seizures
Absence of memory in relation to drinking episodes
Loss of consciousness lasting less than ten minutes
The physician orders venlafaxine (Effexor) for a client with the diagnosis of major depressive disorder and who has been taking herbal medications. When discussing this medication with the client, the nurse should determine if the client has been taking:
Ginseng
Valerian
Kava-kava
St. John's wort
Methylphenidate (Ritalin) is prescribed to treat a 7-year-old child's attention-deficit-hyperactivity disorder (ADHD). Ritalin is used in the treatment of this disorder in children for its:
Diuretic effect
Synergistic effect
Paradoxical effect
Hypotensive effect
The physician orders alprazolam (Xanax) 0.25 mg PO three times a day for a client with anxiety and physical symptoms related to work pressures. The nurse should assess the client for the most common side effect of this medication, which is:
Drowsiness
Bradycardia
Agranulocytosis
Tardive dyskinesia
The nurse determines that after administering alprazolam (Xanax) it is important to assess the client for side effects. Initially the nurse should:
Measure urinary output
Monitor the blood pressure
Assess for abdominal distention
Check the size of the pupils frequently
A client's family asks about the treatment of schizophrenia. Before responding, the nurse recalls that:
Electroconvulsive therapy is more effective in treating schizophrenia than mood disorders
Family therapy has not proven to be effective in the treatment of clients with schizophrenia
Insight therapy has proven to be highly successful in the treatment of clients with schizophrenia
Drug therapy, although not eliminating the underlying problem, reduces the symptoms of acute schizophrenia
A young adult being treated for substance abuse asks the nurse about methadone. The nurse responds that methadone is useful in the treatment of narcotic addiction because it:
Is a nonaddictive drug
Has an effect of longer duration
Has no cumulative effect in the body
Carries little risk of psychologic dependence
To prevent life-threatening complications from the administration of the neuroleptic drug chlorpromazine (Thorazine) to a disturbed, acting-out client, it is important that the nurse:
Provide adequate restraint
Monitor the client's vital signs
Protect against exposure to direct sunlight
Watch the client for extrapyramidal side effects
On the psychiatric unit, a client has been receiving high doses of haloperidol (Haldol) for 2 weeks. The client states, "I just can't sit still and I feel jittery." The nurse suspects that the client may be experiencing the side effect known as:
Akathisia
Torticollis
Tardive dyskinesia
Parkinsonian syndrome
In addition to hydration during delirium tremens, the physician prescribes parenteral administration of lorazepam (Ativan) for the client. The nurse understands that this drug is given during detoxification primarily to:
Prevent physical injury to the client when seizures occur
Enable the client to sleep better during periods of agitation
Quiet the client and encourage cooperation and acceptance of treatment
Reduce the anxiety-tremor state and prevent more serious withdrawal symptoms
The physician orders routine lithium levels to be performed. How many hours after the last dose of lithium should the nurse obtain the blood specimen?
2 to 4
4 to 6
6 to 8
8 to 12
A client has recently been prescribed a new neuroleptic drug. The nurse observes extrapyramidal symptoms and anticipates that the physician will limit these side effects by prescribing:
Zolpidem (Ambien)
Hydroxyzine (Atarax)
Dantrolene (Dantrium)
Benztropine mesylate (Cogentin)
The nurse is aware that haloperidol (Haldol) is most effective for clients who exhibit behavior that is:
Manic
Overactive
Depressed
Withdrawn
A client who is taking lithium arrives at the mental health center for a routine visit. The client has slurred speech, has an ataxic gait, and complains of nausea. The nurse recognizes that these adaptations are:
Related to low lithium levels
Associated with cyclic mood disorders
Often related to therapeutic lithium levels
Probably associated with toxic levels of lithium
The immediate treatment for a client who has ingested a tricyclic antidepressant in an amount that is 20 to 30 times the daily recommended dose should include:
Dialysis or forced diuresis
Administration of physostigmine
IM or IV administration of an anticholinergic
Closer monitoring to prevent further suicidal attempts
A noncompliant, suspicious client with schizophrenia is to be discharged. The client will live with an aging mother and attend an outreach group. The nurse recognizes that the medication most appropriate for this client would be:
Amitriptyline (Elavil)
Tranylcypromine (Parnate)
Fluphenazine hydrochloride (Prolixin)
Fluphenazine decanoate (Prolixin Decanoate)
For a client suspected of and demonstrating the symptoms associated with opiate overdose, the nurse should expect the physician to prescribe:
Naloxone
Methadone
Epinephrine
Amphetamine
The nurse should teach a client receiving tranylcypromine (Parnate) that failure to adhere to the dietary restrictions can result in:
Syncope
Bradycardia
Hypertensive crisis
Hyperglycemic episodes
When talking with a client who has been receiving paroxetine (Paxil), an antidepressant medication, the nurse diagnoses the presence of a knowledge deficit when the client states:
"I will be a little drowsy in the mornings."
"I'm expecting to feel somewhat better and won't need other therapy."
"I've been on the medication for 8 days now and I don't feel any better."
I know I will probably have to take this medication for at least a few months."
A 50-year-old divorced mother has become increasingly depressed, and the physician prescribes an antidepressant. After 20 days of therapy, she returns to the clinic. She appears relaxed and smiles at the nurse. The most significant conclusion the nurse can draw from this behavior is that the client:
Wants to please the staff
Has resolved her conflicts
May be in denial of her problems
Is responding to the antidepressant therapy
A client is extremely depressed, and the physician orders a tricyclic antidepressant, imipramine hydrochloride (Tofranil). The client asks the nurse what the medication will do. The nurse's best response is:
"This medication will help you forget why you are depressed."
"The medication helps increase your appetite, making you feel better."
"When you take this along with phenelzine [Nardil], you'll feel less depressed."
"You will begin to feel much better after taking this medication for 2 to 3 days."
A client with an organic mental disorder becomes increasingly agitated and abusive. The physician orders haloperidol (Haldol). The nurse should assess the client for untoward effects including:
Jaundice and vomiting
Tardive dyskinesia and nausea
Hiccups and postural hypotension
Parkinsonism and agranulocytosis
A client with schizophrenia is given an antipsychotic drug. The nurse is aware that of all the extrapyramidal effects associated with this type of drug, the one causing the most concern is:
Akathisia
Tardive dyskinesia
Parkinsonian syndrome
Acute dystonic reaction
A client with schizophrenia, undifferentiated type, is receiving a typical antipsychotic/neuroleptic. The nurse should be alert for extrapyramidal signs and symptoms, which include:
Shuffling gait, tremors, and restlessness
Nausea, vomiting, and muscular cramps
Drowsiness, disorientation, and slurred speech
Tachycardia, urinary retention, and constipation
The physician orders haloperidol (Haldol) 10 mg PO twice a day for a client who is also receiving phenytoin (Dilantin) for control of epilepsy. When planning the client's care, the nurse should be aware that anticonvulsants may interact with Haldol to:
Mask its therapeutic effect
Interfere with its absorption
Enhance its rate of metabolism
Potentiate its CNS depressant effect
Bupropion (Wellbutrin) has a unique side effect not shared by most other drugs of its class. The nurse should assess the client for which possible side effect of this drug?
Heart failure
Breast tumors
Tardive dyskinesia
Generalized seizures
The nurse has completed a teaching session with a client starting mood-stabilizing medications. The client comment that indicates to the nurse that further teaching is needed is:
"I realize that I will need to keep in touch with my doctor."
"I know I won't have to stay on this medication for too long."
"Taking medication without using other forms of therapy may not be as effective."
"Taking the medication is better than experiencing the highs and lows I have been having."
A client is receiving haloperidol (Haldol) for agitation. When observing the client for side effects, the nurse would recognize that the side effect that is unrelated to extrapyramidal tract symptoms is: