A Nurse is Caring for a Client Who is Experiencing Acute Alcohol with Drawal

60. What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal? A. Risk for injury R/T central nervous system stimulation B. Disturbed thought processes R/T tactile hallucinations C. Ineffective coping R/T powerlessness over alcohol use D. Ineffective denial R/T continued alcohol use despite negative consequences 60. Nurse Stacy is caring for Mr. Moore, who is in acute alcohol withdrawal. She should anticipate the provider will prescribe which of the following medications? Lorazapam 60. Nurse Stacy is planning care for Mr. Moore. Which of the following nursing interventions is appropriate for a client in alcohol withdrawal? Promote a low stimulation environment A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect? A) Muscle aches and chills B) Fatigue and depression C) Anxiety and diaphoresis D) Arrhythmia and respiratory depression 69. A nurse is caring for a client who has been hospitalized for alcohol withdrawal. The client decides to attend an Alcoholics Anonymous meeting. What is a basic principle of this group? 1 Spouses should attend Al-Anon meetings 2 A commitment to permanent abstinence must be made 3 Amends must be made to each person who has been harmed 4 People have the power to overcome alcoholism if they truly want to stop drinking 61. A nurse in the ED is implementing a plan of care for an older adults client who is experiencing delirium tremens. Which of the following actions should the nurse take first? A. Administer diazepam B. Raise the side rails of the bed C. Obtain a medical history D. Start IV fluids 61. Which nursing intervention is a priority when planning nursing care for a client experiencing delirium tremens (DTs) related to alcohol withdrawal? 1. Administer benzodiazepine medication as ordered. 2. Monitor labs for ammonia levels and coagulation times. 3. Take vital signs frequently to monitor for hypovolemic shock. 4. Provide a well-balanced meal and encourage fluids A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens(severe alcohol withdrawal symptoms such as shaking, confusion, and hallucinations). Which of the following actions should the nurse take first? Lower the bed 48. An assessment of a child reveals deficits in communication and social interaction. The child tends to engage in repetitive behaviors such as arranging and rearranging toys. Based on this assessment, the healthcare provider suspect which of the following disorders? A. Tourette Disorder B. ADHA C. Intellectual development disorder D. Autism spectrum disorder 48. The provider is assessing a child who has a diagnosis of autistic spectrum disorder. Which of these clinical findings supports this diagnosis? A. Annoys others deliberately B. Uninterested in playing with others C. Cries for attention at inappropriate times D. Utilizes manipulative behavior 71. A group of nurses are reviewing information about suicide and associated concepts. The group demonstrates understanding of the information when they define which term as the probability that a person will successfully complete suicide? A) Parasuicide B) Suicidal ideation C) Suicidality D) Lethality 71. A nurse has just completed a suicide risk assessment of a widowed client, 76 years of age. In addition to documenting the presence or absence of suicidal thoughts, a suicide plan, and the client's available means, the nurse would also document which information? A) Use of substances 6 hours before the assessment B) Speech patterns C) Availability of support resources D) Amount of sleep in past 24 hours 71. The nurse is caring for a group of hospitalized clients with various psychiatric diagnoses. The nurse identifies which client as having the greatest risk for a suicide attempt? A) Man with bipolar I disorder B) Woman with acute stress disorder C) Man with major depressive disorder D) Woman with somatoform disorder 71. Which method would a nurse use to determine a client's potential risk for suicide? a. Wait for the client to bring up the subject of suicide. b. Observe the client's behavior for cues of suicide ideation. c. Question the client directly about suicidal thoughts. d. Question the client about future plans. 54. A nurse is participating as a speaker in a public workshop on the topic of promoting mental health in young and middle-aged adults. The nurse tells the audience that age, unemployment, and lower education are risk factors associated with mental illness. A woman raises her hand and asks, Does that mean because I only have a 10th grade education and am unemployed that I will develop a mental illness? Which response by the nurse would be most appropriate? A: No, not necessarily; it just means that there is an increased chance that you might. 58. What interventions should the nurse implement to help families of clients in palliative care grieve? Select all that apply. - Helping family say goodbye - Helping family maintain hope - Use of therapeutic presence - Helping caregivers make sense for their feelings 58. A nurse is with a client who is experiencing acute grief. What interventions are appropriate to help a client in grief? Select all that apply. - "This must be very difficult for you." - Maintaining eye contact with the client - Actively listening to the client express her feelings A patient with suicidal impulses is on the highest level of suicide precautions. Which measures should the nurse incorporate into the patient's plan of care? Select all that apply. a. Allow no glass or metal on meal trays. b. Remove all potentially harmful objects from the patient's possession. c. Maintain arm's length, one-on-one nursing observation around the clock. d. Check the patient's whereabouts every hour. Make verbal contact at least three times each shift. e. Check the patient's whereabouts every 15 minutes, and make frequent verbal contacts. f. Keep the patient within visual range while he or she is awake. Check every 15 to 30 minutes while the patient is sleeping. A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder? Anhedonia The nurse is trying to effectively provide culturally competent care for a client. To best meet the client's needs, what should the nurse do? acquire knowledge about the cultural group A psychiatric-mental health nurse is working on developing cultural competence. Which would be most appropriate for the nurse to do? Research information about the cultures of the population being served after assessing the client. Recognize that one's own culture is the predominant way of addressing a client's health care needs. Assume that any individual of a racial or ethnic group is the same as another individual in that group. Demonstrate an appreciation of, and a genuine interest in, the individual and his or her cultural beliefs. A nurse is caring for a client who has Wernicke-Korsakoff syndrome due to alcohol use disorder. What finding should the nurse expect? Confusion A nurse is providing teaching to a client who has generalized anxiety disorder and a new prescription for buspirone. The nurse should inform the client that which manifestations is a common adverse effect of this medication? Dizziness then nurse instructs the parent of a child with ADHD to administer methylphenidate (ritalin) before 4 pm. which side effect is the nurse addressing by giving this instruction? 1. nausea 2. insomnia 3. lethargy 4. anorexia A nurse counsels the parents of a child with autistic disorder. The parents say, "We are going to completely redecorate our child's room. We think that will help." Select the nurse's best response. 1. "Children with autistic disorder usually prefer that things stay the same." 2. "Bright colors are often stimulating for children with autistic disorder." 3. "Remember to not use rugs so that your child will not slip and fall." 4. "New toys and games will help develop your child's intellectual abilities." A nurse counsels the parents of a five-year-old child diagnosed with severe autism spectrum disorder (ASD). When suggesting activities, which activity is most likely to engage this child? 1. Singing with a choir of young children 2. Playing video games with an older child 3. Riding bicycles with a small group of children 4. Assembling and disassembling a simple toy, alone A patient prepares for discharge from the emergency department after treatment for injuries associated with intimate partner violence. The patient plans to return home. Which action by the nurse has priority? Provide the patient with contact information for the local shelter. A client under lithium medication suffered from diarrhea and vomiting. Which of the following nursing intervention should the nurse in charge do first? A. Recognize this as a drug interaction B. Give the client Cogentin C. Reassure the client that these are common side effects of lithium therapy D. Hold the next dose and obtain an order for a stat serum lithium level A nurse is reviewing laboratory results for a client who has schizophrenia and is taking clozapine. Which of the following values should the nurse identify as a contraindication for receiving clozapine? 1. WBC 2500/mm3 2. Hgb 11.5 mg/dL 3. Platelets 150,000/mm3 4. RBC 3.5 million/mm3 A nurse on a medical-surgical unit is assessing a client who sustained injuries 12 hr ago following a motor-vehicle crash. The client's admission blood alcohol level was 325 mg/dL. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal? 1. Somnolence 2. Blood pressure 154/96 mm Hg 3. Pinpoint pupils 4. Blood glucose 210 mg/dL A nurse is providing teaching to a client who has schizophrenia and a new prescription for olanzapine. Which of the following adverse effects of the medication should the nurse instruct the client to report to the provider? 1. Hypertension 2. Blurred vision 3. Urinary frequency 4. Drooling