Final - Ch 14-18 Flashcards
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.
A
A nurse evaluates a client’s patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance dependence?
A.
Narcotic pain medication is contraindicated for all clients with active substance-abuse problems.
B.
Clients who are dependent on alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control.
C.
There is no need to assess the client for substance dependence. There is an obvious PCA malfunction, because these clients have a higher pain tolerance.
D.
The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam (Ativan) dosage.
B
On the first day of a client’s alcohol detoxification, which nursing intervention should take priority?
A.
Strongly encourage the client to attend 90 Alcoholics Anonymous meetings in 90 days.
B.
Educate the client about the biopsychosocial consequences of alcohol abuse.
C.
Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol.
D.
Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.
C
Which client statement indicates a knowledge deficit related to substance abuse?
A.
“Although it’s legal, alcohol is one of the most widely abused drugs in our society.”
B.
“Tolerance to heroin develops quickly.”
C.
“Flashbacks from LSD use may reoccur spontaneously.”
D.
“Marijuana is like smoking cigarettes. Everyone does it. It’s essentially harmless.”
D
A lonely, depressed divorcée has been self-medicating with cocaine for the past year. Which term should a nurse use to best describe this individual’s situation?
A. Psychological dependency B. Physical dependency C. Substance dependency D. Social dependency
A
Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during alcohol withdrawal?
A. Antagonist therapy B. Deterrent therapy C. Codependency therapy D. Substitution therapy
D
A client diagnosed with chronic alcohol dependency is being discharged from an inpatient treatment facility after detoxification. Which client outcome, related to Alcoholics Anonymous (AA), would be most appropriate for a nurse to discuss with the client during discharge teaching?
A.
After discharge, the client will immediately attend 90 AA meetings in 90 days.
B.
After discharge, the client will rely on an AA sponsor to help control alcohol cravings.
C.
After discharge, the client will incorporate family in AA attendance.
D.
After discharge, the client will seek appropriate deterrent medications through AA.
A
A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 24 hours. When the nurse reports to the ED physician, which client symptom should be the nurse’s first priority?
A. Tactile hallucinations B. Blood pressure of 180/100 mm Hg C. Mood rating of 2/10 on numeric scale D. Dehydration
B
Which client statement demonstrates positive progress toward recovery from substance abuse?
A.
“I have completed detox and therefore am in control of my drug use.”
B.
“I will faithfully attend Narcotic Anonymous (NA) when I can’t control my carvings.”
C.
“As a church deacon, my focus will now be on spiritual renewal.”
D.
“Taking those pills got out of control. It cost me my job, marriage, and children.”
D
A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse’s rationale for this intervention?
A. To assess for emotional strength. B. To assess for Wernicke-Korsakoff syndrome. C. To assess for tachycardia. D. To assess for fine tremors.
D
Upon admission to an inpatient treatment facility for symptoms of alcohol withdrawal, a client states, “I haven’t eaten in 3 days.” A nurse’s assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97°F (36°C) with dry skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing diagnosis?
A. Knowledge deficit B. Fluid volume excess C. Imbalanced nutrition: less than body requirements D. Ineffective individual coping
C
A mother who has a history of chronic heroin use has lost custody of her children due to abuse and neglect. She has been admitted to an inpatient substance-abuse program. Which client statement should a nurse associate with a positive prognosis for this client?
A.
“I’m not going to use heroin ever again. I know I’ve got the willpower to do it this time.”
B.
“I cannot control my use of heroin. It’s stronger than I am.”
C.
“I’m going to get all my children back. They need their mother.”
D.
“Once I deal with my childhood physical abuse, recovery should be easy.”
B
A client’s wife has been making excuses for her alcoholic husband’s work absences. In family therapy, she states, “His problems at work are my fault.” Which is the appropriate nursing response?
A.
“Why do you assume responsibility for his behaviors?”
B.
“Codependency is a typical behavior of spouses of alcoholics.”
C.
“Your husband needs to deal with the consequences of his drinking.”
D.
“Do you understand what the term enabler means?”
C
Which medication orders should a nurse anticipate for a client who has a history of complicated withdrawal from benzodiazepines?
A.
Haloperidol (Haldol) and fluoxetine (Prozac)
B.
Carbamazepine (Tegretol) and donepezil (Aricept)
C.
Disulfiram (Antabuse) and lorazepan (Ativan)
D.
Chlordiazepoxide (Librium) and phenytoin (Dilantin)
D
During group therapy, a client diagnosed with chronic alcohol dependence states, “I would not have boozed it up if my wife hadn’t been nagging me all the time to get a job. She never did think that I was good enough for her.” How should a nurse interpret this statement?
A.
The client is using denial by avoiding responsibility.
B.
The client is using displacement by blaming his wife.
C.
The client is using rationalization to excuse his alcohol dependence.
D.
The client is using reaction formation by appealing to the group for sympathy.
C
A nurse is interviewing a client in an outpatient substance-abuse clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish?
A.
The client will identify one person to turn to for support.
B.
The client will give up all old drinking buddies.
C.
The client will be able to verbalize the effects of alcohol on the body.
D.
The client will correlate life problems with alcohol use.
D
A nurse is reviewing the stat laboratory data of a client in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur?
A. 50 mg/dL B. 100 mg/dL C. 250 mg/dL D. 300 mg/dL
B
A client has a history of drinking one pint of bourbon per day for the past 6 months. He is brought to an emergency department by family members who report that his last drink was 1 hour ago. It is now 12 a.m. When should a nurse expect this client to begin experiencing withdrawal symptoms?
A. Between 3 a.m. and 11 a.m. B. Shortly after a 24-hour period. C. At the beginning of the third day. D. Withdrawal is individualized and cannot be predicted.
A
A client diagnosed with depression and substance abuse has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions?
A.
Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance.
B.
Sedative-hypnotics are expensive and have numerous side effects.
C.
Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep.
D.
Sedative-hypnotics are not as effective to promote sleep as antidepressant medications.
A
A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client’s safety?
A. Assess for medication noncompliance. B. Note escalating behaviors and intervene immediately. C. Interpret attempts at communication. D. Assess triggers for bizarre, inappropriate behaviors.
B
A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be included in the nurse’s teaching?
A. The side effects of medications B. Deep breathing techniques to decrease stress C. How to make eye contact when communicating D. How to be a leader
C
A 16-year-old-client diagnosed with paranoid schizophrenia experiences command hallucinations to harm others. The client’s parents ask a nurse, “Where do the voices come from?” Which is the appropriate nursing response?
A.
“Your child has a chemical imbalance of the brain, which leads to altered thoughts.”
B.
“Your child’s hallucinations are caused by medication interactions.”
C.
“Your child has too little serotonin in the brain, causing delusions and hallucinations.”
D.
“Your child’s abnormal hormonal changes have precipitated auditory hallucinations.”
A
Parents ask a nurse how they should reply when their child, diagnosed with paranoid schizophrenia, tells them that voices command him to harm others. Which is the appropriate nursing response?
A.
“Tell him to stop discussing the voices.”
B.
“Ignore what he is saying, while attempting to discover the underlying cause.”
C.
“Focus on the feelings generated by the hallucinations and present reality.”
D.
“Present objective evidence that the voices are not real.”
C
A nurse is assessing a client diagnosed with paranoid schizophrenia. The nurse asks the client, “Do you receive special messages from certain sources, such as the television or radio?” For which potential symptom of this disorder is the nurse assessing?
A. Thought insertion B. Paranoid delusions C. Magical thinking D. Delusions of reference
D
A client diagnosed with schizophrenia tells a nurse, “The ‘Shopatouliens’ took my shoes out of my room last night.” Which is an appropriate charting entry to describe this client’s statement?
A.
“The client is experiencing command hallucinations.”
B.
“The client is expressing a neologism.”
C.
“The client is experiencing a paranoid delusion.”
D.
“The client is verbalizing a word salad.”
B
During an admission assessment, a nurse asks a client diagnosed with schizophrenia, “Have you ever felt that certain objects or persons have control over your behavior?” For which type of thought disruption is the nurse assessing?
A. Delusion of persecution B. Delusions of influence C. Delusions of reference D. Delusions of grandeur
B
A client diagnosed with schizophrenia states, “Can’t you hear him? It’s the devil. He’s telling me I’m going to hell.” Which is the most appropriate nursing response?
A.
“Did you take your medicine this morning?”
B.
“You are not going to hell. You are a good person.”
C.
“I’m sure the voices sound scary, but the devil is not talking to you. This is part of your illness.”
D.
“The devil only talks to people who are receptive to his influence.”
C
A client diagnosed with psychosis NOS tells a nurse about voices telling him to kill the president. Which nursing diagnosis should the nurse prioritize for this client?
A. Disturbed sensory perception B. Altered thought processes C. Risk for violence: directed toward others D. Risk for injury
C
Which nursing intervention would be most appropriate when caring for an acutely agitated client diagnosed with paranoid schizophrenia?
A.
Provide neon lights and soft music.
B.
Maintain continual eye contact throughout the interview.
C.
Use therapeutic touch to increase trust and rapport.
D.
Provide personal space to respect the client’s boundaries.
D
Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia?
A.
Establishing personal contact with family members.
B.
Being reliable, honest, and consistent during interactions.
C.
Sharing limited personal information.
D.
Sitting close to the client to establish rapport.
B
A client diagnosed with paranoid schizophrenia states, “My psychiatrist is out to get me. I’m sad that the voice is telling me to stop him.” What symptom is the client exhibiting, and what is the nurse’s legal responsibility related to this symptom?
A.
Magical thinking; administer an antipsychotic medication.
B.
Persecutory delusions; orient the client to reality.
C.
Command hallucinations; warn the psychiatrist.
D.
Altered thought processes; call an emergency treatment team meeting.
C
Which statement should indicate to a nurse that an individual is experiencing a delusion?
A. “There’s an alien growing in my liver.” B. “I see my dead husband everywhere I go.” C. “The IRS may audit my taxes.” D. “I’m not going to eat my food. It smells like brimstone.”
A
A client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should a nurse expect a physician to order to address this type of symptom?
A.
Haloperidol (Haldol) to address the negative symptom.
B.
Clonazepam (Klonopin) to address the positive symptom.
C.
Risperidone (Risperdal) to address the positive symptom.
D.
Clozapine (Clozaril) to address the negative symptom.
C
A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine?
A. Tactile hallucinations B. Tardive dyskinesia C. Restlessness and muscle rigidity D. Reports of hearing disturbing voices
C
A nurse is caring for a client who is experiencing a flat affect, paranoid delusions, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the client’s positive and negative symptoms of schizophrenia?
A.
Paranoid delusions, anhedonia, and anergia are positive symptoms of schizophrenia.
B.
Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia.
C.
Paranoid delusions, anergia, and echolalia are negative symptoms of schizophrenia.
D.
Paranoid delusions, flat affect, and anhedonia are negative symptoms of schizophrenia.
B
A 60-year-old client diagnosed with chronic schizophrenia presents in an emergency department (ED) with uncontrollable tongue movements, stiff neck, and difficulty swallowing. Which medical diagnosis and treatment should a nurse anticipate when planning care for this client?
A.
Neuroleptic malignant syndrome treated by discontinuing antipsychotic medications.
B.
Agranulocytosis treated by administration of clozapine (Clozaril).
C.
Extrapyramidal symptoms treated by administration of benztropine (Cogentin).
D.
Tardive dyskinesia treated by discontinuing antipsychotic medications.
D
After taking chlorpromazine (Thorazine) for 1 month, a client presents to an emergency department (ED) with severe muscle rigidity, tachycardia, and a temperature of 105oF (40.5?C). Which medical diagnosis and treatment should a nurse anticipate when planning care for this client?
A.
Neuroleptic malignant syndrome treated by discontinuing Thorazine and administering dantrolene (Dantrium).
B.
Neuroleptic malignant syndrome treated by increasing Thorazine dosage and administering an antianxiety medication.
C.
Dystonia treated by administering trihexyphenidyl (Artane).
D.
Dystonia treated by administering bromocriptine (Parlodel).
A
A client diagnosed with schizophrenia takes an antipsychotic agent daily. Which assessment finding should a nurse address first?
A. Respirations of 22 beats/minute B. Weight gain of 8 pounds in 2 months C. Temperature of 104°F (40°C) D. Excessive salivation
C
