Ch. 36- NCLEX Saunders- Ch. 67 Flashcards
- The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action would the nurse take to plan appropriate nursing care?
a. Ask the client why they started taking illegal drugs.
b. Ask the client about the amount of drug use and its effect.
c. Ask the client how long they thought that they could take drugs without someone finding out.
d. Avoid asking any questions for fear that the client is in denial and will throw the nurse out of the home.
b. Ask the client about the amount of drug use and its effect.
- Which interventions are most appropriate for caring for a client in alcohol withdrawal? (Select all that apply.)
a. Monitor vital signs.
b. Provide a safe environment.
c. Address hallucinations therapeutically.
d. Provide stimulation in the environment.
e. Provide reality orientation as appropriate.
f. Maintain NPO (nothing by mouth) status.
a. Monitor vital signs.
b. Provide a safe environment.
c. Address hallucinations therapeutically.
e. Provide reality orientation as appropriate.
- The nurse determines that the spouse of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the spouse make which statement?
a. “I no longer feel that I deserve the beatings my partner inflicts on me.”
b. “My attendance at the meetings has helped me to see that i provoke my partner’s violence.”
c. “I enjoy attending the meetings because they get me out of the house and away from my partner.”
d. “I can tolerate my partner’s destructive behaviors now that I know they are common among alcoholics.”
a. “I no longer feel that I deserve the beatings my partner inflicts on me.”
- A hospitalized client with a history of alcohol misuse tells the nurse: “I am leaving now. I must go. I do not want any more treatment. I have things that I have to do right away.” The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client’s concerns with the client, the client dresses and begins to walk out of the hospital room. What action would the nurse take?
a. Call the nursing supervisor.
b. Call security to block all exit areas.
c. Restrain the client until the primary health care provider (PHCP) can be reached.
d. Tell the client that the client cannot return to this hospital again if the client leaves now.
a. Call the nursing supervisor.
- The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings would the nurse expect to note? (Select all that apply.)
a. Dental decay
b. Moist, oily skin
c. Loss of tooth enamel
d. Electrolyte imbalances
e. Body weight well below ideal range
a. Dental decay
c. Loss of tooth enamel
d. Electrolyte imbalances
- The nurse is caring for a client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client’s room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate?
a. Allow the client to complete the exercise pro-gram.
b. Interrupt the client and weigh the client immediately.
c. Tell the client that exercising rigorously is not al-lowed.
d. Interrupt the client and offer to take the client for a walk.
d. Interrupt the client and offer to take the client for a walk.
- A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed room. A newly admitted client will be assigned to this client’s room. Which client would be the best choice as a roommate for the client with anorexia nervosa?
a. A client with pneumonia
b. A client undergoing diagnostic tests
c. A client who thrives on managing others
d. A client who could benefit from the client’s assistance at mealtime
b. A client undergoing diagnostic tests
- The nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. Which findings would alert the nurse to the potential for alcohol withdrawal delirium?
a. Hypotension, ataxia, hunger
b. Stupor, lethargy, muscular rigidity
c. Hypotension, coarse hand tremors, lethargy
d. Hypertension, changes in level of consciousness, hallucinations
d. Hypertension, changes in level of consciousness, hallucinations
- The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, “I need to get out of this bad situation.” Which is the most helpful response by the nurse?
a. “Why don’t you tell your spouse about this?”
b. “What do you find difficult about this situation?”
c. “This is not the best time to make that decision.”
d. “I agree with you. You should get out of this situation.”
b. “What do you find difficult about this situation?”
- A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes an interest in buying new clothes but expresses that money is limited. Group members have brought some used clothes to the client to replace the client’s old clothes. The client believes that the new clothes are much too tight and has reduced personal caloric intake to 800 calories daily. How would the nurse evaluate this behavior?
a. Normal behavior
b. Evidence of the client’s disturbed body image
c. Regression as the client is moving toward the community
d. Indicative of the client’s ambivalence about hospital discharge
b. Evidence of the client’s disturbed body image
