TEST 3: Personality Disorders, Substance- Related Disorders, Anxiety Disorders, and Anxiety-Related Disorders

Question 1

The Client with a Personality Disorder
1. A client has been diagnosed with Avoidant Personality Disorder. He reports loneliness, but
has fears about making friends. He also reports anxiety about being rejected by others. In designing a
long-term treatment plan, in what order, from first to last, should the nurse include the following?
1. Teach the client anxiety management and social skills.
2. Ask the client to join one of his chosen activities with the nurse and two other clients.
3. Talk with the client about his self-esteem and his fears.
4. Help the client make a list of small group activities at the center he would find interesting.

Answer 1

The Client with a Personality Disorder
1.
3. Talk with the client about his self-esteem and his fears.
1. Teach the client anxiety management and social skills.
4. Help the client make a list of small group activities at the center he would find interesting.
2. Ask the client to join one of his chosen activities with the nurse and two other clients.
The client needs a stepwise plan for developing a social life. He needs to first work on his self-
esteem and reduce his fears of rejection before talking about how to decrease his anxiety and learning
new social skills. Helping him chose interesting activities is important before suggesting an activity
for him. Then he will be ready to try a structured activity with the nurse present for support and role
modeling.
CN: Psychosocial integrity; CL: Synthesize

Question 2

2. A client diagnosed with borderline personality disorder has self-inflicted cuts on her arms.
   The nurse is assessing the client for the risk of suicide. What should the nurse ask the client first?
3. About medications she has taken recently.
4. If she is taking antidepressants.
   If she has a suicide plan.
5. Why she cut herself.

Answer 2

2. 3. The client is at risk for suicide, and the nurse should determine how serious the client is,
      including if she has a plan and the means to implement the plan. While medication history may be
      important, the nurse should first attempt to determine suicide risk. Asking the client why she cut
      herself will likely cause the client to respond with insufficient information to determine suicide risk.
      CN: Reduction of risk potential; CL: Synthesize

Question 3

3. When developing the plan of care for a client diagnosed with a personality disorder, the nurse
   plans to assist the client primarily with which of the following?
   Specific dysfunctional behaviors.
4. Psychopharmacologic compliance.
5. Examination of developmental conflicts.
6. Manipulation of the environment.

Answer 3

3. 1. The nurse should plan to assist the client who has a personality disorder primarily with
      specific dysfunctional behaviors that are distressing to the client or others. The client with a
      personality disorder has lifelong, inflexible, and dysfunctional patterns of relating and behaving. The
      client commonly does not view his behavior as distressful to himself. The client becomes distressed
      because of others’ reactions and behaviors toward him, which cause the client emotional pain and
      discomfort. Psychopharmacologic compliance is not a primary need because medication does not
      cure a personality disorder. Medication is prescribed if the client has a severe symptom that
      interferes with functioning, such as severe anxiety or depression, or if the client has an Axis Idisorder. Examination of developmental conflicts usually is not helpful because of the ingrained
      dysfunctional ways of thinking and behaving. It is more useful to help the client with changing
      dysfunctional behaviors. Although milieu management is a component of care, the client usually is
      proficient in manipulation of the environment to meet his needs.
      CN: Psychosocial integrity; CL: Synthesize

Question 4

4. A client diagnosed with paranoid personality disorder is hospitalized for physically
   threatening his wife because he suspects her of having an affair with a coworker. Which of the
   following approaches should the nurse employ with this client?
5. Authoritarian.
6. Parental.
   Matter-of-fact.
7. Controlling.

Answer 4

4. 3. For this client, the nurse needs to use a calm, matter-of-fact approach to create a
      nonthreatening and secure environment because the client is experiencing problems with
      suspiciousness and trust. Use of “I” statements and responses would be therapeutic to reduce the
      client’s suspiciousness and increase his trust in the staff and the environment. An authoritarian
      approach is nontherapeutic and inappropriate because the client may perceive this approach as an
      attack, subsequently responding with anger and threatening behavior. A parental or controlling
      approach may be perceived as authoritarian, and the client may become defensive and angry.
      CN: Safety and infection control; CL: Synthesize

Question 5

5. When planning care for a client diagnosed with schizotypal personality disorder, which of thefollowing helps the client become involved with others?
6. Participating solely in group activities.
7. Being involved with primarily one-to-one activities.
8. Leading a sing-along in the afternoon.
9. Attending an activity with the nurse.

Answer 5

5. 4. Attending an activity with the nurse assists the client to become involved with others slowly.
      The client with a schizotypal personality disorder needs support, kindness, and gentle suggestion to
      improve social skills and interpersonal relationships. The client commonly has problems in thinking,
      perceiving, and communicating and appears similar to clients with schizophrenia except that
      psychotic episodes are infrequent and less severe. Participation solely in group activities or leading a
      sing-along would be too overwhelming for the client, subsequently increasing the client’s anxiety and
      withdrawal. Engaging primarily in one-to-one activities would not be helpful because of the client’s
      difficulty with social skills and interpersonal relationships. However, activities with the nurse could
      be used to establish trust. Then the client could proceed to activities with others.
      CN: Psychosocial integrity; CL: Synthesize

Question 6

6. A client is complaining to other clients about not being allowed by staff to keep food in her
   room. The nurse should:
7. Ignore the client’s behavior.
   Set limits on the behavior.
8. Reprimand the client.
9. Allow the snack to be kept in her room.

Answer 6

6. 2. The nurse needs to set limits on the client’s manipulative behavior to help the client control
      dysfunctional behavior. The manipulative client bends rules to have her needs met without regard for
      rules or the needs or rights of others. A consistent approach by the staff is necessary to decrease
      manipulation. Ignoring the client’s behavior reinforces or promotes the continuation of the client’s
      manipulative behavior. Reprimanding the client may be perceived as a threat, resulting in aggressive
      behavior. Allowing the client to keep a snack in her room reinforces the dysfunctional behavior.
      CN: Psychosocial integrity; CL: Synthesize

Question 7

7. A client with an Axis II diagnosis of antisocial personality disorder has a potential for
   violence and aggressive behavior. Which of the following client outcomes to be accomplished in the
   short term is most appropriate for the nurse to include in the plan of care?
8. Use humor when expressing anger.
   Discuss feelings of anger with staff.
9. Ask the nurse for medication when upset.
10. Use indirect behaviors to express anger.

Answer 7

7. 2. The nurse assists the client with identifying and putting feelings into words during one-to-one
      interactions. This helps the client express her feelings in a nonthreatening setting and avoid directing
      anger toward other clients. A client with an antisocial personality disorder needs to understand how
      others feel and react to her behaviors and why they react the way they do. The client also needs to
      understand the consequences of her behaviors. Using humor or indirect behaviors to express anger is
      a passive–aggressive method that will not help the client learn how to express her anger
      appropriately. Asking the nurse for medication when upset is a way to avoid dealing with feelings and
      is not helpful. However, medication may be necessary if talking and engaging in a physical activity
      have not been effective in lowering anxiety or if the client is about to lose control of her behavior.
      CN: Psychosocial integrity; CL: Synthesize

Question 8

8. A new client on the psychiatric unit has been diagnosed with depression and obsessive-
   compulsive personality disorder (OCPD). During visiting hours, her husband states to the nurse that
   he doesn’t understand this OCPD and what can be done about it. What information should the nurse
   share with the client and her husband? Select all that apply.
9. Perfectionism and overemphasis on tasks usually interfere with friendships and leisure time.
10. It will help to interrupt her tasks and tell her you are going out for the evening.
11. There are medicines, such as clomipramine (Anafranil) or fluoxetine (Prozac) that may help.
12. Remind your wife that it is “OK” to be human and make mistakes.
13. Reinforce with her that she is not allowed to expect the whole family to be perfect too.
14. This disorder typically involves inflexibility and a need to be in control.

Answer 8

8. 1, 3, 4, 6. Inflexibility, need to be in control, perfectionism, overemphasis on work or tasks,
   and a fear of making mistakes are common symptoms of OCPD. Anafranil and Prozac may help withthe obsessive symptoms, Interrupting the client’s tasks is likely to increase her anxiety even more.
   Telling her that she cannot expect the family to be perfect is likely to create a power struggle.
   CN: Psychosocial integrity; CL: Apply

Question 9

9. A client diagnosed with paranoid personality disorder is being admitted on an Immediate
   Detention Order (24-hour hold) after a physical altercation with a police officer who was
   investigating the client’s threatening phone calls to his neighbors. He states that his neighbors are
   spying on him for the government. “I want them to stop and leave me alone. Now they have you nurses
   and doctors involved in their conspiracy.” Which of the following nursing approaches are most
   appropriate? Select all that apply.
10. Approach the client in a professional, matter-of-fact manner.
11. Avoid intrusiveness in interactions with the client.
12. Gently present reality to counteract the client’s current paranoid beliefs.
13. Develop trust consistently with the client.
14. Do not pressure the client to attend any groups.

Answer 9

9. 1, 2, 4, 5. A professional, matter-of-fact approach and developing trust are the most effective
   with this client. A friendly approach, intrusiveness, and attempting to counteract the client’s beliefs
   will increase the client’s paranoia; he will present more false beliefs to prove he is right about the
   conspiracy. In groups, questions from peers, confrontations with reality, and the emotionality will
   increase the client’s anxiety.
   CN: Management of care; CL: Analyze

Question 10

9. A client diagnosed with paranoid personality disorder is being admitted on an Immediate
   Detention Order (24-hour hold) after a physical altercation with a police officer who was
   investigating the client’s threatening phone calls to his neighbors. He states that his neighbors are
   spying on him for the government. “I want them to stop and leave me alone. Now they have you nurses
   and doctors involved in their conspiracy.” Which of the following nursing approaches are most
   appropriate? Select all that apply.
   Approach the client in a professional, matter-of-fact manner.
   Avoid intrusiveness in interactions with the client.
10. Gently present reality to counteract the client’s current paranoid beliefs.
    Develop trust consistently with the client.
11. Do not pressure the client to attend any groups.

Answer 10

10. 4. Some characteristics of a client with a dependent personality are an inability to make daily
       decisions without advice and reassurance and the preoccupation with fear of being alone to care for
       oneself. The client needs others to be responsible for important areas of his life. The nurse should
       respond, “Your parents have been supportive of you and will continue to be supportive even if you
       live apart,” to gently challenge the client’s fears and suggest that they may be unwarranted. Stating,
       “You’re a 28-year-old adult now, not a child who needs to be cared for,” or “Your parents need a
       break, and you need a break from them,” is reprimanding and would diminish the client’s self-worth.
       Stating, “Your parents won’t be around forever; after all they are getting older,” may be true, but it is
       an insensitive response that may increase the client’s anxiety.
       CN: Psychosocial integrity; CL: Apply

Question 11

11. A client moves in with her family after her boyfriend of 4 weeks told her to leave. She is
    admitted to the subacute unit after reporting feeling empty and lonely, being unable to sleep, and
    eating very little for the last week. Her arms are scarred from frequent self-mutilation. The nurse
    should do which of the following from first to last?
12. Monitor for suicide and self-mutilation.
13. Discuss the issues of loneliness and emptiness.
14. Monitor sleeping and eating behaviors.
15. Discuss her housing options for after discharge.

Answer 11

11.
1. Monitor for suicide and self-mutilation.
3. Monitor sleeping and eating behaviors.
2. Discuss the issues of loneliness and emptiness.
4. Discuss her housing options for after discharge.
Safety is the priority concern and then eating and sleeping patterns need to be reestablished. After
intervening to meet basic needs, delving into the loneliness and emptiness are important for
determining underlying issues that need to be followed up in outpatient counseling. Although the client
is living with her family currently, other options might be appropriate for her to consider.
CN: Safety and infection control; CL: Synthesize

Question 12

12. The client approaches various staff with numerous requests and needs to the point of
    disrupting the staff’s work with other clients. The nurse meets with the staff to decide on a consistent,
    therapeutic approach for this client. Which of the following approaches will be most effective?
13. Telling the client to stay in his room until staff approach him.
14. Limiting the client to the dayroom and dining area.
15. Giving the client a list of permissible requests.
16. Having the client address needs to the staff person assigned.

Answer 12

12. 4. For the client with attention-seeking behaviors, the nurse would institute a behavioral
       contract with the client to help decrease dysfunctional behaviors and promote self-sufficiency. Having
       the client approach only his assigned staff person sets limits on his attention-seeking behavior. Telling
       the client to stay in his room until staff approach him, limiting the client to a certain area, or giving the
       client a list of permissible requests is punitive and does nothing to help the client gain control over
       the dysfunctional behavior.CN: Management of care; CL: Synthesize

Question 13

13. The client with diagnosed borderline personality disorder tells the nurse, “You’re the best
    nurse here. I can talk to you and you listen. You’re the only one here that can help me.” Which of the
    following responses by the nurse is most therapeutic?
14. “Thank you; you’re a good person.”
15. “All of the nurses here provide good care.”
16. “Other clients have told me that too.”
17. “Mary and Sam are good nurses too.”

Answer 13

13. 2. The most therapeutic response is, “All of the nurses here provide good care.” This
       statement corrects the client’s unrealistic and exaggerated perception. “Splitting,” defined as the
       inability to integrate good and bad aspects of an individual and the self, is a hallmark behavior of a
       client with borderline personality disorder. The client sees himself and others as all good or all bad.
       Components of “splitting” include behaviors that idealize and devalue others. It is a defense that
       allows the client to avoid pain and feelings associated with past abuse or a current situation involving
       the threat of rejection or abandonment. The other statements promote the client’s idealistic view and
       do nothing to help correct the client’s distortion.
       CN: Psychosocial integrity; CL: Apply

Question 14

14. The client diagnosed with borderline personality disorder is admitted to the unit after having
    attempted to cut her wrists with a pair of scissors. The client has several scars on both arms from
    self-mutilation and suicide gestures. A staff member states to the nurse, “It’s just attention that shewants, she’s not going to kill herself.” The nurse should respond to the staff member by saying:
15. “She’s here now and we have to do our best.”
16. “She needs to be here until she can control her behavior.”
17. “I’m ashamed of you; you know better than to say that.”
18. “Any attempt at self-harm is serious, and safety is a priority.”

Answer 14

14. 4. The client with borderline personality disorder is usually in a crisis situation when
       hospitalized for self-mutilation and suicidal ideation or behavior. The statement, “Any attempt at self-
       harm is serious and safety is a priority,” is the best response because the misperception that self-
       mutilation is used to gain attention can result in death of the client. The client can accidentally commit
       suicide. Any form of self-harm is an indication that the client needs treatment. The statement, “She’s
       here now and we have to do our best,” is not helpful and does not educate the staff member about the
       client’s needs. The statement, “She needs to be here until she can control her behavior,” may be true
       but does not provide information about the client’s priority needs. The statement, “I’m ashamed of you;
       you know better than to say that,” is punitive, diminishes self-worth, and may not be a correct
       assumption of the staff member’s knowledge.
       CN: Management of care; CL: Synthesize

Question 15

15. The nurse assesses a client to be at risk for self-mutilation and implements a safety contract
    with the client. Which of the following client behaviors indicate that the contract is working?
16. The client withdraws to his room when feeling overwhelmed.
17. The client notifies staff when anxiety is increasing.
18. The client suppresses his feelings when angry.
19. The client displaces his feelings onto the primary health care provider.

Answer 15

15. 2. For the client who is at risk for self-mutilation, the nurse develops a contract to assist the
       client with assuming responsibility for his behavior and to help the client develop adaptive methods
       of coping with feelings. Self-mutilation is usually an expression of intense anxiety, anger,
       helplessness, or guilt or a means to block psychological pain by inducing physical pain. A typical
       contract helpful to the client would have the client notify staff when anxiety is increasing.
       Withdrawing to his room when feeling overwhelmed, suppressing feelings when angry, or displacing
       feelings onto the primary health care provider is not an adaptive method to help the client deal with
       his feelings and could still result in self-mutilation.
       CN: Safety and infection control; CL: Evaluate

Question 16

16. The client diagnosed with borderline personality disorder who is to be discharged soon
    threatens to “do something” to herself if discharged. The nurse should first:
17. Request that the client’s discharge be canceled.
18. Ignore the client’s statement because it’s a sign of manipulation.
19. Ask a family member to stay with the client at home temporarily.
20. Discuss the meaning of the client’s statement with her.

Answer 16

16. 4. Any suicidal statement must be assessed by the nurse. The nurse should discuss the client’s
       statement with her to determine its meaning in terms of suicide, overwhelming feelings of anxiety,
       abandonment, or other need that the client cannot express appropriately. It is not uncommon for a
       client with borderline personality disorder to make threatening comments before discharge. Extending
       the hospital stay is inappropriate because it would encourage dependency and manipulation. Ignoring
       the client’s statement on the assumption that it is a sign of manipulation is an error in judgment. Asking
       a family member to stay with the client temporarily at home is not appropriate and places the
       responsibility for the client on the family instead of the client.
       CN: Psychosocial integrity; CL: Synthesize

Question 17

17. A 19-year-old client is admitted to a psychiatric unit with an Axis I diagnosis of alcohol
    abuse and an Axis II diagnosis of personality disorder not otherwise specified. The client’s mother
    states, “He’s always in trouble, just like when he was a boy. Now he’s just a bigger prankster and out
    of control.” In view of the client’s history, which of the following is most important initially?
18. Letting the client know the staff has the authority to subdue him if he gets unruly.
19. Keeping the client isolated from other clients until he is better known by the staff.
20. Emphasizing to the client that he will have to pay for any damage he causes.
21. Closely observing the client’s behavior to establish a baseline pattern of functioning.

Answer 17

17. 4. The best initial course of action when admitting a client is to observe him to establish
       baseline information. This assessment provides valuable information about the client’s behavior and
       forms the basis for the plan of care. Telling the client that the staff has authority to subdue him if hegets unruly or that he will have to pay for any damage he causes is threatening and may incite or
       provoke trouble. Isolating a client is not recommended unless there is a very good reason for it, such
       as a very active, combative client who is dangerous to himself and others.
       CN: Psychosocial integrity; CL: Synthesize

Question 18

18. The client tells the nurse at the outpatient clinic that she doesn’t need to attend groups because
    she’s “not a regular like these other people here.” The nurse should respond to the client by saying:
19. “Because you’re not a regular client, sit in the hall when the others are in group.”
20. “Your family wants you to attend, and they will be very disappointed if you don’t.”
21. “I’ll have to mark you absent from the clinic today and speak to the doctor about it.”
22. “You say you’re not a regular here, but you’re experiencing what others are experiencing.”

Answer 18

18. 4. The best response is, “You say you’re not a regular here, but you’re experiencing what
       others are experiencing.” This statement helps the client to identify factors that precipitate denial by
       helping her to confront that which inhibits compliance. Denial is used to help a client feel better and
       more secure when a situation provokes a high level of anxiety and is threatening to the client. The
       statement, “Because you’re not a regular client, sit in the hall when the others are in group,” agrees
       with and promotes denial in the client and interferes with treatment. The statement, “Your family
       wants you to attend and they will be disappointed if you don’t,” causes the client to feel guilty and
       decreases her self-esteem. The statement, “I’ll have to mark you absent from the clinic today and
       speak to the doctor about it,” is punitive and threatening to the client, subsequently decreasing her
       self-esteem.
       CN: Psychosocial integrity; CL: Synthesize

Question 19

19. The client who has a history of using angry outbursts when frustrated begins to curse at the
    nurse during an appointment after being informed that she will have to wait to have her medication
    refilled. Which of the following responses by the nurse is most appropriate?
20. “You’re being very childish.”
21. “I’m sorry if you can’t wait.”
22. “I will not continue to talk with you if you curse.”
23. “Come back tomorrow and your medication will be ready.”

Answer 19

19. 3. Stating, “I will not continue to talk with you if you curse,” sets limits on the client’s
       behavior and points out the negative effects of her behavior. Therefore, this response is most
       appropriate and therapeutic. The statement, “You’re being very childish,” reprimands the client,
       possibly causing the anger to escalate. The statement, “I’m sorry if you can’t wait,” fails to provide
       feedback to the client about her behavior. The statement, “Come back tomorrow and your medication
       will be ready,” ignores the client’s behavior, failing to provide feedback to the client about the
       behavior. It also shows poor nursing judgment because the client may need her medication before
       tomorrow or may not return to the clinic the following day.
       CN: Psychosocial integrity; CL: Synthesize

Question 20

20. Which of the following behaviors indicates to the nurse that the client diagnosed with
    avoidant personality disorder is improving?
21. Interacting with two other clients.
22. Listening to music with headphones.3. 3. Sitting at a table and painting.
23. Talking on the telephone.

Answer 20

20. 1. The client with avoidant personality disorder is showing signs of improvement when
       interacting with two other clients. A client with avoidant personality disorder is timid, socially
       uncomfortable, withdrawn, and hypersensitive to criticism. Social contact with others decreases
       isolation and withdrawal. Listening to music with headphones, sitting at a table and painting, and
       talking on the telephone are solitary activities and therefore do not indicate improvement, which is
       evidenced by social contact.
       CN: Psychosocial integrity; CL: Analyze

Question 21

21. One evening the client takes the nurse aside and whispers, “Don’t tell anybody, but I’m going
    to call in a bomb threat to this hospital tonight.” Which of the following actions is the priority?
22. Warning the client that his telephone privileges will be taken away if he abuses them.
23. Offering to disregard the client’s plan if he does not go through with it.
24. Notifying the proper authorities after saying nothing until the client has actually completed the call.
25. Explaining to the client that this information will have to be shared immediately with the staff and the
    primary health care provider

Answer 21

21. 4. The priority is to explain to the client that this information has to be shared immediately
       with the staff and the primary health care provider because of its serious nature. Safety of all is
       crucial regardless of whether the client follows through on his plan. It is possible that the client is
       asking to be stopped and that he is indirectly pleading for help in a dysfunctional manner. Bargaining
       with the client, such as warning him that his telephone privileges will be taken away if he abuses
       them or offering to disregard his plan if he does not go through with it, is inappropriate. Saying
       nothing to anyone until the client has actually completed the call and then notifying the proper
       authorities represent serious negligence on the part of the nurse.
       CN: Safety and infection control; CL: Synthesize

Question 22

22. When teaching a nursing assistant new to the unit about the principles for the care of a client
    diagnosed with a personality disorder, the nurse should explain that:
23. The clients are accepted although their behavior may not be.
24. Clients need limits on their behavior.
25. The staff members are the primary ones left to care about these clients.
26. The staff should use minimal humor when working with these clients.

Answer 22

22. 1. The most basic and important idea to convey to a client is that, as a person, he or she is
       accepted, although his or her behavior may not be. Empathy is conveyed for emotional painregardless of the client’s behavior. Although some clients need limits placed on their behavior, not all
       clients require limit setting. That the staff members are the primary ones left to care about these
       clients is not necessarily true, nor is it true that the staff should use very little humor with these
       clients. Clients who are rigid and perfectionists and who have a restricted affect may need help with
       displaying humor.
       CN: Management of care; CL: Apply

Question 23

23. The nurse is talking with a client who has been diagnosed with antisocial personality
    disorder about how to socialize during activities without being seductive. The nurse should focus the
    discussion on which of the following areas?
24. Explaining the negative reactions of others toward his behavior.
25. Suggesting he apologize to others for his behavior.
26. Asking him to explain the reasons for his seductive behavior.
27. Discussing his relationship with his mother.

Answer 23

23. 1. The nurse should explain the negative reactions of others toward the client’s behaviors to
       make him aware of the impact of his seductive behaviors on others. Suggesting that the client
       apologize to others for his behavior is futile because the client cannot feel remorse for wrongdoing.
       Asking him to explain reasons for his seductive behavior is not helpful because this client is skillful
       at using projection and rationalization. Discussing his relationship with his mother is not helpful
       because the focus should be oriented to the present situation and managing his behavior at the present
       time.
       CN: Psychosocial integrity; CL: Synthesize

Question 24

24. Which of the following approaches is most appropriate to use with a client diagnosed with a
    narcissistic personality disorder when discrepancies exist between what the client states and what
    actually exists?
25. Limit setting.
26. Supportive confrontation.
27. Consistency.
28. Rationalization.

Answer 24

24. 2. The nurse would specifically use supportive confrontation with the client to point out
       discrepancies between what the client states and what actually exists to increase responsibility for
       self. Limit setting and consistency also may be used. However, limit setting helps the client control
       unacceptable behavior and consistency helps reduce the frequency of negative behaviors; they do not
       point out discrepancies. Rationalization is typically used by the client, not the nurse, to blame others,
       make excuses, and provide alibis for self-centered behaviors.
       CN: Psychosocial integrity; CL: Synthesize

Question 25

25. The client with histrionic personality disorder is melodramatic and responds to others and
    situations in an exaggerated manner. The nurse should recommend which of the following activities
    for this client?
26. Party planning.
27. Music group.
28. Cooking class.
29. Role-playing.

Answer 25

25. 4. The nurse should use role playing to teach the client appropriate responses to others in
       various situations. This client dramatizes events, draws attention to self, and is unaware of and does
       not deal with feelings. The nurse works to help the client clarify true feelings and learn to express
       them appropriately. Party planning, music group, and cooking class are therapeutic activities, but will
       not help the client specifically learn how to respond appropriately to others.
       CN: Psychosocial integrity; CL: Synthesize

Question 26

The Client with an Alcohol-Related Disorder
26. A client has been diagnosed with dementia related to chronic and heavy alcohol consumption.
In a family meeting with the client, discharge plans are being discussed. Which of the following
points should the nurse share with the family and client? Select all that apply.
1. The house and garage need to be searched and all the alcohol products destroyed.
2. Without continued alcohol intake, the client will gradually get better.
3. With the memory loss, answer the client’s question once, and then ignore that question when
asked again.
4. Safety alarms on the doors will help to keep the client from wandering off.
5. As the need for supervision increases, it may be necessary for the client to be placed in an extended
care facility.

Answer 26

The Client with an Alcohol-Related Disorder
26. 4, 5. As with any dementia, there is a need to protect the client from wandering off and risking
harm to self. Dementia is progressive and eventually requires 24-hour supervision. Destroying the
alcohol is notably ineffective; the client will find a way to get more if quitting is not a personal goal.
Not answering the client’s question will generally increase the client’s anger. Once the dementia is
evident, lack of alcohol intake will not reverse the condition.
CN: Psychosocial integrity; CL: Create

Question 27

27. In an outpatient addictions group, a recovering client said that before her treatment, her
    husband drank on social occasions. “Now he drinks at home, from the time he comes home from work
    until he goes to bed. He says that he doesn’t like me anymore and that I expect him to do more work on
    the house and yard. I use to ignore that stuff. I don’t know what to do.” The nurse would make the
    following comments in which order of priority from first to last?
28. “What do you think you could do to have your husband come in for an evaluation?”
29. “I hear how confused and frustrated you are.”
30. “It can happen that as one person sobers up, the spouse deteriorates.”
31. “What have you tried to do about your husband’s behaviors?”

Answer 27

27.
2. “I hear how confused and frustrated you are.”
3. “It can happen that as one person sobers up, the spouse deteriorates.”4. “What have you tried to do about your husband’s behaviors?”
1. “What do you think you could do to have your husband come in for an evaluation?”
The client’s feelings and concerns need to be validated, so that she will open up more. She also
should know that the changes in her husband are not unusual. It helps to know the client has tried with
her husband to determine if they are appropriate or not. Then there can be a discussion about getting
help for her husband, so that her efforts to stay sober are not compromised.
CN: Reduction of risk potential; CL: Analyze

Question 28

28. For the client who has difficulty falling asleep at night because of withdrawal symptoms from
    alcohol, which are abating, which of the following nursing interventions is likely to be most
    effective?
29. Inviting the client to play a board game with the nurse.
30. Allowing the client to sit in the community room until the client feels sleepy.
31. Advising the client to sleep on the sofa in the dayroom.
32. Teaching the client relaxation exercises to use before bedtime.

Answer 28

28. 4. The best action by the nurse to help a client who has difficulty falling asleep would be to
       teach the client relaxation exercises to use before bedtime to reduce anxiety and promote relaxation.
       This activity will also be useful for the client when out of the hospital. Inviting the client to play a
       board game is inappropriate because this activity can be competitive and thus stimulate the client.
       Allowing the client to sit in the community room until she feels sleepy is inappropriate because it
       does nothing to help the client relax; nor does advising the client to sleep on the sofa in the dayroom,
       which may be against unit policy.
       CN: Basic care and comfort; CL: Synthesize

Question 29

29. A client known to have alcohol dependence is admitted to the emergency department with atemperature of 99°F (37.2°C), a pulse of 110, respirations of 26, and blood pressure of 150/98. The
    blood alcohol level is 0.25%, three times the legal limit. Now the client is becoming belligerent and
    uncooperative. In which order from first to last should the following nursing and medical
    prescriptions be implemented?
30. Administer lorazepam 2 mg IM.
31. Draw blood for a magnesium level.
32. Take vital signs every 15 minutes.
33. Place the client in a quiet room with dimmed lights.

Answer 29

29.
4. Place client in a quiet room with dimmed lights.
1. Administer lorazepam 2 mg IM
2. Draw blood for a magnesium level.
3. Take vital signs every 15 minutes.
The nurse should first place the client in a quieter, darkened room with dimmer lights to decrease
the stimuli from the busy emergency department (ED) and create a more calming environment. Next,
the nurse should administer the lorazepam to help decrease agitation and reduce the risk of seizures.
Drawing the blood will be easier as the client becomes less agitated. Depending on the magnesium
blood level, the client may need an intramuscular (IM) dose of magnesium sulfate to prevent seizures.
The nurse can then obtain the vital sign every 15 minutes to determine if the client is becoming
stabilized and if the client needs further doses of lorazepam.
CN: Management of care; CL: Synthesize

Question 30

30. A client has been admitted to the emergency department with alcohol withdrawal delirium.
    The nurse is assessing the client for signs of withdrawal. At 9 AM on 10/25, the nurse notes that the
    client is confused. Vital signs are T = 99°F (37.2°C), P = 50, R = 10, and BP = 100/60. The nurse
    compares these findings to the nurses’ progress notes from admission 24 hours ago (see below).

PROGRESS NOTES
10/24/13 9 pm – T 99 F (37.2 C) P 110, R 18 , BP = 140/90; client has IV D5W keep open rate started; diazepam adminitered as prescribed ; Client Oriented x 2.

10/25/13 1am – T 99.2 F (37.3 C) P 90, R 14; BP 130/80 ; client resting

10/25/13 5am – T 99 F (37.2 C) P 70 R 14 BP 126/80;client oriented x3

What should the nurse do first?

1. Contact the primary health care provider.
2. Increase the rate of the IV infusion.
3. Attempt to arouse the client.
4. Administer magnesium sulfate.

Answer 30

30. 1. The nurse should first contact the primary health care provider. The client’s vital signs and
       level of consciousness are deteriorating, indicating complications of withdrawal, which can be life
       threatening. Increasing the rate of the infusion may cause fluid overload and has not been prescribed
       by the primary health care provider. Arousing the client will not address the underlying problems.Magnesium sulfate is used to treat seizures precipitated by alcohol withdrawal, but the client is not
       demonstrating signs of actual or impending seizures.
       CN: Safety and infection control; CL: Synthesize

Question 31

31. An intoxicated client is admitted to the hospital for alcohol withdrawal. Which of the
    following should the nurse do to help the client become sober?
32. Give the client black coffee to drink.
33. Walk the client around the unit.
34. Have the client take a cold shower.
35. Provide the client with a quiet room to sleep in.

Answer 31

31. 4. The nurse should provide the client with a quiet room to sleep in. Alcohol is destroyed and
       oxidized in the body at a slow, steady rate. The rate of alcohol metabolism is not influenced by
       drinking black coffee, walking around the unit, or taking a cold shower. Therefore, it is best to have
       the client sleep off the effects of the alcohol.
       CN: Reduction of risk potential; CL: Synthesize

Question 32

32. The client is admitted to the hospital for alcohol detoxification. Which of the following
    interventions should the nurse use? Select all that apply.
33. Taking vital signs.
34. Monitoring intake and output.
35. Placing the client in restraints as a safety measure.
36. Reinforcing reality if the client is disoriented or hallucinating.
37. Explaining to the client that the symptoms of withdrawal are temporary.

Answer 32

32. 1, 2, 4, 5. For the client experiencing symptoms of alcohol withdrawal, the nurse monitors
    vital signs and intake and output, reinforces reality for the client who is confused, disoriented, or
    hallucinating, explains that the symptoms of withdrawal are temporary, reduces stimulation, and stays
    with the client if he is confused or agitated. The nurse administers medications to prevent the
    progression of symptoms, such as seizures and delirium tremens, and to ensure the client’s safety.
    Restraints are not used as a precautionary measure. Restraints are used only as a least restrictive
    measure to protect the client and others when the client is a danger to himself or others.
    CN: Psychosocial integrity; CL: Synthesize

Question 33

33. The nurse is assessing a client who has fallen twice in the last 2 days. The client has been
    diagnosed with delirium tremens (DTs) following withdrawal from alcohol use. The nurse should
    further evaluate the client for which of the following? Select all that apply.
34. Disorientation.
35. Paralysis.
36. Elevated temperature.
37. Diaphoresis.
38. Visual or auditory hallucinations.

Answer 33

33. 1, 3, 4, 5. Two or three days after cessation of alcohol, clients may experience delirium
    tremens (DTs), as evidenced by disorientation, nightmares, abdominal pain, nausea, and diaphoresis,
    as well as elevated temperature, pulse, and blood pressure, and visual and auditory hallucinations. If
    the client had a traumatic brain injury after falling, the client might have paralysis, but there is no
    association of paralysis from DTs.
    CN: Physiologic adaptation; CL: Synthesize

Question 34

34. A client was discharged from an alcohol rehabilitation program on clonazepam 0.5 mg three
    times a day. Several months later he reports having insomnia, shakiness, sweating, and one seizure.
    The nurse should first ask the client if he:
35. Has been drinking alcohol with the clonazepam.
36. Has developed tolerance to the clonazepam and needs to increase the dose.
37. Has stopped taking the clonazepam suddenly.
38. Is having a panic attack and needs to take an extra clonazepam.

Answer 34

34. 3. The nurse should first confirm that the client has stopped taking the clonazepam because the
       client is reporting symptoms of benzodiazepine withdrawal from stopping the clonazepam abruptly.
       The client would report symptoms of being sedated if he took alcohol with the clonazepam. Tolerance
       symptoms would be increased anxiety, not these physical symptoms. Clonazepam is an appropriate
       medication for panic attacks, but taking extra pills without primary health care provider approval is
       not appropriate.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 35

35. A client is entering the chemical dependency unit for treatment of alcohol dependency. Which
    of the client’s possessions should the nurse place in a locked area?
36. Toothpaste.
37. Dental floss.
38. Shaving cream.
39. Antiseptic mouthwash.

Answer 35

35. 4. Antiseptic mouthwash commonly contains alcohol and should be kept in a locked area
       unless labeling clearly indicates that the product does not contain alcohol. A client with an intense
       craving for alcohol may drink mouthwash that contains alcohol. Personal care items, such as
       toothpaste, dental floss, and shaving cream, do not contain alcohol, and the client would be allowed
       to keep them in the room.
       CN: Safety and infection control; CL: Synthesize

Question 36

Antiseptic mouthwash.
36. A client is entering rehabilitation for alcohol dependency as an alternative to going to jail for
multiple DUIs (driving under the influence). While obtaining the client’s history, the nurse asks about
the amount of alcohol he consumes daily. He responds, “I just have a few drinks with the guys after
work.” Which of the following responses by the nurse is most therapeutic?
1. “That’s what all the clients here say at first.”
2. “Then you should have had a designated driver for yourself.”
3. “I guess you just can’t handle a few drinks.”
4. “You say you have a few drinks, but you have multiple arrests.”

Answer 36

36. 4. The best way to intervene with a client’s minimization or denial of alcohol problems is to
       point out the consequences of the drinking—the multiple arrests. The other responses are superficial
       and discount the seriousness of the client’s problem.
       CN: Psychosocial integrity; CL: Synthesize

Question 37

37. While admitting a client to the alcohol treatment program, the nurse asks the client how long
    she’s been drinking, how much she’s been drinking, and when she had her last drink. The client replies
    that she has been drinking about a liter of vodka a day for the past week and her last drink was about
    an hour ago. This information helps the nurse to determine which of the following?
38. The severity of the disease.
39. The severity of withdrawal symptoms.
40. The possibility of alcoholic hallucinosis.
41. The occurrence of delirium tremens.

Answer 37

37. 2. The client’s response helps the nurse determine the severity of withdrawal symptomsbecause the length and extent of drinking alcohol has an effect on the severity of symptoms the client
       experiences during withdrawal. Decreased use of alcohol can also result in withdrawal symptoms in
       the client who has developed a high tolerance to alcohol and is physically dependent. The severity of
       the disease, the possibility of hallucinations, and the occurrence of delirium tremens are not
       determined by the information given. The Axis I diagnosis of alcohol dependency is just that—it is
       not classified as mild, moderate, or severe. Alcoholic hallucinosis is a state of auditory
       hallucinations that develops about 48 hours after the client has stopped drinking. The client hears
       voices or noises within the context of a clear sensorium, meaning that the auditory hallucination is the
       only symptom the client experiences. Severe withdrawal symptoms that are not managed medically
       can progress to delirium tremens or a severe abstinence syndrome. Delirium tremens occurs about 3
       to 5 days after the client’s last drink and is characterized by confusion, agitation, severe psychomotor
       activity, hallucinations, sleeplessness, tachycardia, elevated blood pressure, elevated temperature,
       and possibly seizures.
       CN: Reduction of risk potential; CL: Analyze

Question 38

38. A client who is experiencing alcohol withdrawal exhibits tremors, diaphoresis, and
    hyperactivity. Blood pressure is 190/87 mm Hg and pulse is 92 bpm. Which of the following
    medications should the nurse expect to administer?
39. Haloperidol (Haldol).
40. Lorazepam (Ativan).
41. Benztropine (Cogentin).
42. Naloxone (Narcan).

Answer 38

38. 2. The nurse would most likely administer a benzodiazepine, such as lorazepam, to the client
       who is experiencing symptoms of alcohol withdrawal. The benzodiazepine substitutes for the alcohol
       to suppress withdrawal symptoms. The client experiences symptoms of withdrawal because of the
       “rebound phenomenon” when sedation of the central nervous system (CNS) from alcohol begins to
       decrease. Haloperidol (Haldol) is an antipsychotic and is not indicated for alcohol withdrawal
       symptoms. Benztropine is used to treat extrapyramidal symptoms associated with antipsychotic
       therapy. Naloxone is used in opioid overdose to reverse the CNS depression caused by the opioid.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 39

39. Which of the following assessments provides the best information about the client’s
    physiologic response and the effectiveness of the medication prescribed specifically for alcohol
    withdrawal?
40. Nutritional status.
41. Evidence of tremors.
42. Vital signs.
43. Sleep pattern.

Answer 39

39. 3. Monitoring vital signs provides the best information about the client’s overall physiologic
       status during alcohol withdrawal and the physiologic response to the medication used. Vital signs
       reflect the degree of central nervous system irritability and indicate the effectiveness of the
       medication in easing withdrawal symptoms. Although assessment of nutritional status and sleep
       pattern and assessment for evidence of tremors are important, they provide only indirect information
       about single aspects of the client’s physiologic status.
       CN: Reduction of risk potential; CL: Analyze

Question 40

40. A client who had been drinking heavily over the weekend could not remember specific events
    of where he had been or what he had done. The nurse interprets this information as indicating that the
    client experienced which of the following conditions?
41. Blackout.
42. Hangover.
43. Tolerance.
44. Delirium tremens.

Answer 40

40. 1. A client is suffering from a blackout when he cannot recall what he did while under the
       influence of alcohol. A hangover refers to symptoms experienced the day after a bout of heavy
       drinking. Common symptoms include headaches and gastrointestinal distress, typically after heavy
       alcohol consumption. Tolerance refers to the need to increase the amount of the substance or to ingest
       the substance more often to achieve the same effects. Delirium tremens refers to severe alcohol
       withdrawal or abstinence syndrome with confusion, psychomotor agitation, sleeplessness,
       hallucinations, and elevated vital signs.
       CN: Physiological adaptation; CL: Analyze

Question 41

41. A client is entering the alcohol treatment program for the fourth time in 5 years. Which of the
    following statements by the nurse will be most helpful to the client?
42. “I hope you are serious about maintaining your sobriety this time.”
43. “I’m Maria, a nurse here. I don’t know you from past attempts, but you’ll get it right this time.”
44. “I know someone who was successful after the fifth program.”
45. “I’m Maria, a nurse in the program. The staff and I will help you through the program.”

Answer 41

41. 4. Stating, “I’m Maria, a nurse in the program; the staff and I will help you,” is a
       nonjudgmental, caring approach that promotes trust and a therapeutic relationship. The statement, “I
       hope you are serious about maintaining your sobriety this time,” blames the client, subsequently
       decreasing the client’s self-worth. Saying, “You’ll get it right this time” is threatening to the client,
       possibly leading to decreased self-worth by reinforcing the client’s past failures at maintainingsobriety. The statement, “I know someone who was successful after the fifth program,” is impersonal
       and irrelevant to the client’s situation.
       CN: Psychosocial integrity; CL: Synthesize

Question 42

42. The wife of a client with alcohol dependency tells the nurse, “I’m tired of making excuses for
    him to his boss and coworkers when he can’t make it into work. I believe him every time he says he’s
    going to quit.” The nurse recognizes the wife’s statement as indicating which of the following
    behaviors?
43. Helpfulness.
44. Self-defeat.
    Enabling.
45. Masochism.

Answer 42

42. 3. The wife of the man with alcohol dependency is exhibiting enabling behavior when she
       makes excuses for her husband’s absenteeism. Enabling behavior is not helpful to the client but
       rescues him from adverse consequences in relation to his employment. Self-defeating behavior would
       be evidenced by putting oneself in a position that will lead to failure. Masochistic behavior would be
       evidenced by the need to experience emotional or physical pain to become sexually aroused.
       CN: Psychosocial integrity; CL: Analyze

Question 43

43. Which of the following statements by the nurse participating in a group confrontation of a
    coworker is most helpful in reducing the coworker’s denial about alcohol being a problem?
44. “Your behavior is unprofessional.”
45. “As a nurse, you should have sought help earlier.”
46. “Nurses are the worst when it comes to asking for help.”
47. “You have alcohol on your breath.”

Answer 43

43. 4. To be most helpful, the nurse should calmly and objectively present facts by saying, “You
       have alcohol on your breath,” to help the coworker overcome denial and resistance. This statement
       also helps to reinforce the coworker’s awareness of the problem. The other statements blame the
       coworker and may reinforce denial. Blaming, nagging, and yelling diminish self-esteem in the
       individual with a substance abuse problem who has low frustration tolerance.
       CN: Psychosocial integrity; CL: Synthesize

Question 44

44. The husband of a nurse who is being confronted by a group about her problem with alcohol
    asks the nurse acting as the group leader what he should say to his wife during the meeting. The nurse
    leader directs the husband to use which of the following statements to facilitate his wife’s entrance
    into treatment?
45. “The children and I want you to get help.”
46. “If your parents were alive, they would be extremely disappointed in you.”
47. “Either you get help or the kids and I will move out of the house.”
48. “You need to enter treatment now or be a drunk if that’s what you want.”

Answer 44

44. 3. The nurse leader should direct the husband to say, “Either you get help or the kids and I
       will move out of the house.” This statement facilitates entrance into treatment because it is a direct
       statement of what the consequences are if the alcohol abuse continues. The statement, “The children
       and I want you to get help,” is not effective. Most likely, the husband has already made a similar
       statement before the confrontation session. Saying, “If your parents were alive, they would be
       extremely disappointed in you,” or “You need to enter treatment now or be a drunk if that’s what you
       want,” shames the wife and further decreases her self-esteem.
       CN: Management of care; CL: Synthesize

Question 45

45. A nurse working in an alcohol rehabilitation program is teaching staff how to give clients
    constructive feedback. Which of the following statements given as an example illustrates that the staff
    member understands the nurse’s teaching regarding the use of constructive feedback?
46. “I think you’re a real con artist.”
47. “You’re dominating the conversation.”
48. “You interrupted Terry twice in 4 minutes.”
49. “You don’t give anyone a chance to finish talking.”

Answer 45

45. 3. The statement, “You interrupted Terry twice in 4 minutes,” indicates an understanding of the
       use of constructive feedback by describing specifically what was seen and heard in an objective
       manner. The other statements are judgmental and blame the client without specifying what the
       objectionable behavior is.
       CN: Psychosocial integrity; CL: Evaluate

Question 46

46. A client ashamedly tells the nurse that he hit his wife while intoxicated and asks the nurse if
    his wife will ever forgive him. The nurse should reply to the client by saying:
47. “Perhaps you could ask her and find out.”
48. “That’s something you can explore in family therapy.”
49. “It would depend on how much she really cares for you.”
50. “You seem to have some feelings about hitting your wife.”

Answer 46

46. 4. The client is feeling remorse about hitting his wife. It is best to make a comment that will
       help him focus on his feelings and express them. Reflecting what the client has said is a good
       technique to accomplish these goals. Suggesting the client ask his wife or explore the issue in family
       therapy is inappropriate because it gives advice and ignores the client’s underlying feelings. Saying
       “It would depend on how much she really cares for you” is inappropriate because it ignores the
       client’s feelings and reinforces the negative aspects, such as the shamefulness, of the behavior.
       CN: Psychosocial integrity; CL: Synthesize

Question 47

47. While meeting with the nurse, a client’s wife states, “I don’t know what else to do to makehim stop drinking.” The nurse should refer the wife to which of the following organizations?
48. Alateen.
49. Al-Anon.
50. Employee assistance program.
51. Alcoholics Anonymous.

Answer 47

47. 2. Al-Anon is a self-help group for spouses and significant others that provides education and
       support and helps participants learn to lead their own life without feeling responsible for the
       individual with an alcohol problem. Alateen provides support for teenaged children of a person with
       an alcohol problem. Employee assistance programs help employees recover from alcohol or drug
       dependence while retaining their positions or jobs. Alcoholics Anonymous provides support for the
       individual with alcohol problems to attain and maintain sobriety.CN: Management of care; CL: Apply

Question 48

48. Which of the following nursing actions is contraindicated for the client who is experiencing
severe symptoms of alcohol withdrawal?
1. Helping the client walk.
2. Monitoring intake and output.
3. Assessing vital signs.
4. Using short, concrete statements.

Answer 48

48. 1. Having the client who is experiencing severe symptoms of alcohol withdrawal walk is
       contraindicated because increased activity and stimulation may confuse the client and promote
       hallucinations. The client may also sustain an injury if he has a seizure as part of the alcohol
       withdrawal process. The nurse should monitor intake and output to ensure fluid and electrolyte
       balance and hydration. The nurse should assess vital signs to assess the physiologic status of the
       client and the response to medications. The nurse should use short, concrete statements to decrease
       confusion and ambiguity.
       CN: Reduction of risk potential; CL: Apply

Question 49

49. Which of the following client statements indicates to the nurse that the client needs further
    teaching about disulfiram (Antabuse)?
50. “I can drink one or two beers and not get sick while on Antabuse.”
51. “I can take Antabuse at bedtime if it makes me sleepy.”
52. “A metallic or garlic taste in my mouth is normal when starting on Antabuse.”
53. “I’ll read the labels on cough syrup and mouthwash for possible alcohol content.”

Answer 49

49. 1. Any amount of alcohol consumed while taking disulfiram (Antabuse) can cause an alcohol-
       disulfiram reaction. The reaction experienced is in proportion to the amount of alcohol ingested. The
       alcohol-disulfiram reaction can begin 5 to 10 minutes after alcohol is ingested. Symptoms can be
       mild, as in flushing, throbbing in the head and neck, nausea, and diaphoresis. Other symptoms include
       vomiting, respiratory difficulty, hypotension, vertigo, syncope, and confusion. Severe reactions
       involve respiratory depression, convulsions, coma, and even death. Disulfiram can be taken at
       bedtime if the client feels sleepy from the medication. Some clients experience a metallic or garlic
       taste when initiating disulfiram treatment. Anything containing alcohol, such as cough medicine,
       aftershave lotion, and mouthwash, can cause a reaction. Therefore, the client needs to check the labels
       of these items for their alcohol content.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 50

50. While receiving disulfiram (Antabuse) therapy, the client becomes nauseated and vomits
    severely. Which of the following questions should the nurse ask first?
51. “How long have you been taking Antabuse?”
52. “Do you feel like you have the flu?”
53. “How much alcohol did you drink today?”
54. “Have you eaten any foods cooked in wine?”

Answer 50

50. 3. The first question should be to ask the client how much alcohol she has had today because
       nausea with severe vomiting is a sign of an alcohol-disulfiram (Antabuse) reaction. Asking the client
       whether she feels like she has flu symptoms is important after inquiring about alcohol intake. Foods
       cooked in an alcoholic beverage, such as wine, could also cause a reaction, but the reaction would be
       less severe because the alcohol dissipates with cooking. Asking how long the client has been taking
       Antabuse would be least important at this time.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 51

51. The expected outcome for using thiamine for a client being treated for an alcohol addiction is
    to:
52. Prevent the development of Wernicke’s encephalopathy.
53. Decrease client’s withdrawal symptoms.
54. Aid client in regaining strength sooner.
55. Promote elimination of alcohol from the body faster.

Answer 51

51. 1. Thiamine specifically prevents the development of Wernicke’s encephalopathy, a reversible
       amnestic disorder caused by a diet deficient in thiamine secondary to poor nutritional intake that
       commonly accompanies chronic alcoholism. It is characterized by nystagmus, ataxia, and mental
       status changes. Because the client would rather drink alcohol than eat, the client is depleted of
       vitamins and nutrients. Alcohol also is an irritant that causes a “malabsorption syndrome” in which
       vitamins and nutrients are not absorbed properly in the gastrointestinal tract. Thiamine is not
       associated with decreasing withdrawal symptoms, helping clients regain their strength, or promoting
       elimination of alcohol from the body.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 52

52. Which of the following client statements indicates an understanding of the signs of alcohol
    relapse?
53. “I know I can stay dry if my wife keeps alcohol out of the house.”
54. “Stopping Alcoholics Anonymous (AA) and not expressing feelings can lead to relapse.”
55. “I’ll have my sponsor at AA keep the list of symptoms for me.”
56. “If someone tells me I’m about to relapse, I’ll be sure to do something about it.”

Answer 52

52. 2. The statement, “Stopping AA and not expressing feelings can lead to relapse,” indicates the
       client’s understanding of signs of relapse. The client is responsible for sobriety and must understand
       the signs of relapse. Other antecedents to relapse include severe craving, being around users, and
       severe emotional crises. The other statements place the responsibility for the client’s sobriety on
       someone else.CN: Reduction of risk potential; CL: Evaluate

Question 53

53. The client sees no connection between her liver disorder and her alcohol intake. She believes
    that she drinks very little and that her family is making something out of nothing. The nurse interprets
    these behaviors as indicative of the client’s use of which of the following defense mechanisms?
54. Denial.
55. Displacement.
56. Rationalization.
57. Reaction formation.

Answer 53

53. 1. The client is using denial, an unconscious defense mechanism, when she refuses to
       acknowledge that she has a problem with alcohol. This is further evidenced by the client’s inability to
       connect the liver disorder with alcohol ingestion. Displacement involves transfer of a feeling to
       someone else or to an object. Rationalization involves an attempt to make or prove that one’s feeling
       or behavior is justifiable. Reaction formation is a conscious behavior that is the exact opposite of an
       unconscious feeling.
       CN: Psychosocial integrity; CL: Analyze

Question 54

54. Which of the following foods should the nurse eliminate from the diet of a client in alcohol
withdrawal?
1. Milk.
2. Regular coffee.
3. Orange juice.
4. Eggs.

Answer 54

54. 2. Regular coffee contains caffeine, which acts as a psychomotor stimulant and leads to
       feelings of anxiety and agitation. Serving coffee to the client may add to tremors and wakefulness.
       Milk, orange juice, and eggs are part of a well-balanced, high-protein diet needed by the client in
       alcohol withdrawal, who is nutritionally depleted.
       CN: Reduction of risk potential; CL: Apply

Question 55

55. A client with alcohol dependency has peripheral neuropathy. The nurse should develop a
teaching plan that emphasizes:
1. Washing and drying the feet daily.
2. Massaging the feet with lotion.
3. Trimming the toenails carefully.
4. Avoiding use of an electric blanket.

Answer 55

55. 4. The nurse should teach the client with peripheral neuropathy to avoid using an electric
       blanket because the client is likely to have decreased sensitivity in the extremities owing to the
       damaging effects of alcohol on the nerve endings. It is particularly important to guard against burns
       because the client may not be able to discern the appropriate degree of heat on the feet. Daily washing
       and drying, massaging with lotion, and trimming the toenails are appropriate foot care measures for
       any client.
       CN: Reduction of risk potential; CL: Create

Question 56

56. A client is experiencing alcohol withdrawal. He wakes up and screams, “There’s something
    crawling under my skin. Help me.” In which order, from first to last, should the following nursing
    actions be done?
57. Remind the client that he is having withdrawal symptoms and that these will be treated.
58. Administer a dose of lorazepam (Ativan) depending on the severity of the withdrawal
    symptoms.
59. Assess the client for other withdrawal symptoms.
60. Take the client’s vital signs.
61. Chart the details of the episode on the electronic health record.

Answer 56

56.
1. Remind the client that he is having withdrawal symptoms and that these will be treated.
4. Take the client’s vital signs depending on the severity of the withdrawal symptoms.
3. Assess the client for other withdrawal symptoms.
2. Administer a dose of lorazepam (Ativan).
5. Chart the details of the episode on the electronic health record.
After the nurse reminds the client about this withdrawal symptom, the nurse should take the
client’s vital signs and then assess for other symptoms, such as visual and auditory disturbances,
tremors, anxiety, nausea, and excess perspiration. The elevation of the vital signs also helps to
determine the amount of Ativan needed to control the withdrawal symptoms. The nurse should then
chart the details of the episode and outcomes of the interventions.
CN: Physiological adaptation; CL: Synthesize

Question 57

57. Which of the following measures should the nurse include in the plan of care for a client with
    alcohol withdrawal delirium?
58. Using restraints continuously.
59. Touching the client before saying anything.
60. Remaining with the client when she is confused or disoriented.
61. Informing the client about alcohol treatment programs.

Answer 57

57. 3. The client with alcohol withdrawal delirium should not be left unattended when confused,
       disoriented, or hallucinating. Injury or unintentional suicide is a possibility when the client attempts
       to get away from hallucinations. Restraints are used only when the client loses control and is a danger
       to herself or others, to protect the client from injury or harm. Touching the client before saying
       anything is an additional stimulus that would most likely add to the client’s agitation. Informing the
       client about the alcohol treatment program while the client is delirious is inappropriate and shows
       poor nursing judgment. The client should be given information about alcohol treatment when the
       withdrawal symptoms are lessening and the client can comprehend the information.
       CN: Safety and infection control; CL: Synthesize

Question 58

58. Which of the following is an accurate response when a client asks the nurse about
    requirements to become a member of Alcoholics Anonymous (AA)?
59. “You must be sober for at least a month before joining.”
60. “AA is open to anyone who wants sobriety.”
61. “The members will interview you and decide if you can join the group.”
62. “AA requires daily attendance at meetings.”

Answer 58

58. 2. Alcoholics Anonymous (AA), a self-help program based on 12 steps, is open to anyone
       whose goal is sobriety. The first step requires that the individual admit that he is powerless over
       alcohol and needs help. Members are in various stages of recovery, and the individual does not have
       to be sober for at least a month before joining. Potential members are not interviewed. The individual
       decides how many meetings to attend each week. AA does not require attendance at meetings daily,
       but some individuals choose to do so, especially at the beginning of recovery.
       CN: Management of care; CL: Apply

Question 59

59. A client is to be discharged from an alcohol rehabilitation program. Which of the following
    should the nurse emphasize in the discharge plan as a priority?
60. Supportive friends.
61. A list of goals.
62. Family forgiveness.
63. Follow-up care.

Answer 59

59. 4. Follow-up care is essential to prevent relapse. Recovery has just begun when the treatment
       program ends. The first few months after program completion can be difficult and dangerous for the
       chemically dependent client. The nurse is responsible for discharge plans that include arrangements
       for counseling, self-help group meetings, and other forms of aftercare. Supportive friends, a list of
       goals, and family forgiveness may be important and helpful to the client, but follow-up care is
       essential.
       CN: Management of care; CL: Create

Question 60

60. The client is to be discharged from the hospital after a safe, medically supervised withdrawal
    from alcohol. Which of the following outcomes indicate client readiness for an outpatient alcohol
    treatment program? Select all that apply.
61. The client states the need to cut down on his alcohol intake.
62. The client verbalizes the damaging effects of alcohol on his body.
63. The client plans to attend Alcoholics Anonymous meetings.
64. The client takes naltrexone (ReVia) daily.
65. The client says he is indestructible.

Answer 60

60. 2, 3, 4. The client who plans to attend Alcoholics Anonymous meetings, verbalizes the
    damaging effects of alcohol on his body, and takes naltrexone daily may be ready for alcohol
    rehabilitation. Other key outcomes include admitting that a problem with alcohol exists and realizing
    the negative effects of alcohol on his life. Stating that he needs to cut down on his alcohol intake and
    that he is indestructible are signs of denial of an alcohol problem.
    CN: Management of care; CL: Evaluate

Question 61

61. A client diagnosed with major depression and substance dependence is being admitted to the
    Dual Diagnosis Unit. In explaining the focus of this program, the nurse should tell the client?
62. The addiction will be treated first, then the depression.
63. The depression with be treated first, then the addiction.
64. There will be simultaneous treatment of the addiction and depression.
65. As the addiction is treated, the depression will clear up on its own.

Answer 61

61. 3. The best approach is to treat both illnesses simultaneously. Treating one and not the other is
       ineffective. The depression will not clear just by becoming sober or clean.
       CN: Management of care; CL: Synthesize

Question 62

62. While caring for a client who has a dual diagnosis of bipolar disorder and alcohol
    dependency, which of the following areas is the priority for daily assessment?
63. Sleep pattern.
64. Mental status.
65. Eating habits.
66. Self-care ability.

Answer 62

62. 2. The nurse should assess the client’s mental status daily to note changes that could occur
       from exacerbation of the mental illness or withdrawal from alcohol. Changes in mental status are
       important for treatment issues such as medication and participation in groups. Assessment of mental
       status takes priority because mental status affects the client’s ability to sleep, eat, and care for himself.
       Flexibility is necessary on the part of nurses and staff members who are working with a
       heterogeneous client population.
       CN: Management of care; CL: Analyze

Question 63

63. A client diagnosed with schizophrenia and alcohol abuse decides to drink alcohol with his
    buddies. The nurse recognizes which of the following as the underlying dynamic of the client’s
    alcohol use?
64. The decision to use alcohol is a wish to feel accepted by others.
65. The decision to drink increases the client’s guilt and shame.
66. The client abused alcohol before developing a mental illness.
67. The client is compelled to drink because of cognitive difficulties.

Answer 63

63. 1. The client’s decision to drink results in feeling accepted by his peers which increases his
       self-esteem. Guilt or shame may result later because the client is aware that he should not use alcoholbecause of his mental illness. The combination of a mental illness and substance abuse results in
       increased recidivism and treatment complications. It may not be true that the client abused alcohol
       before developing a mental illness or that the client is compelled to drink because of cognitive
       difficulties. The client may be predisposed to developing a substance abuse problem and a mental
       illness because of heredity and biologic factors.
       CN: Psychosocial integrity; CL: Apply

Question 64

The Client with Disorders Related to Other
Addictive Substances
64. A client is being admitted to the hospital following an inadvertent overdose with oxycodone.
He reveals that he has chronic back pain that resulted from an injury on a construction site. He states,
“I know I took too much oxycodone at once, but I can’t live with this pain without them. You can’t take
them away from me.” Which of the following responses by the nurse is most appropriate?
1. “Once you are tapered off the oxycodone, you will find that nonaddictive pain medicines will
be enough to control your pain.”
2. “You are going to be switched from the oxycodone to methadone for long-term pain
management.
3. The oxycodone will be stopped tomorrow, but you will have lorazepam to help you with the
withdrawal symptoms.
4. Your pain will be controlled by tapering doses of oxycodone, with other pain management strategies
and medicines.

Answer 64

The Client with Disorders Related to Other Addictive
Substances
64. 4. Tapering doses of oxycodone, pain management strategies, and other pain control medicines
are found to be the most helpful with opiate addictions resulting from chronic pain. Nonaddictive
(over-the-counter) medicines alone are generally insufficient for chronic pain management.
Methadone is an addictive opioid that involves substituting one addiction with another, so now clients
are being detoxed off Methadone as well. Lorazepam may help with anxiety during withdrawal from
opiates, but it does not control the other symptoms of opiate withdrawal.
CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 65

65. A school nurse is planning a program for parents on “Drugs Commonly Abused by
    Teenagers.” Which of the following information should be included about inhalants? Select all that
    apply.
66. Monitor for paper bags and rags that may have been used for breathing inhalants.
67. Brain damage is unlikely with the use of inhalants.
68. Use of inhalants by teens is on the decline.
69. Deaths from inhalants occur from asphyxiation, suffocation, and aspiration of vomit.
    Inhalants usually cause depression of the central nervous system.
70. The basic groups of inhalants are hydrocarbon solvents such as glue, aerosol propellants from spray
    cans, and anesthetics/gases.

Answer 65

65. 1, 4, 5, 6. The nurse should instruct the parents to monitor their children for use of paper bags
    or rags. The nurse should present information about brain damage from inhalants including damage to
    the frontal lobe, cerebellum, and hippocampus, and that death is possible. Rather than use being on
    the decline, teenagers are experimenting even more with many types of inhalants, such as Freon,
    ground-up candy disks, and spray cleaners for computer and TV screens.
    CN: Health promotion and maintenance; CL: Create

Question 66

66. The friend of a client brought to the emergency department states, “I guess she had some bad
    junk (heroin) today.” The client is drowsy and verbally nonresponsive. Which of the following
    assessment findings is of immediate concern to the nurse?
67. Respiratory rate of 9 breaths/min.
68. Urinary retention.
69. Hypotension.
70. Reduced pupil size.

Answer 66

66. 1. A respiratory rate of less than 12 breaths/min is cause for concern because of central
       nervous system depression. Respiratory depression and arrest is the primary cause of death among
       clients who abuse opioids. Peripheral nervous system effects associated with opioid abuse include
       urinary retention, hypotension, reduced pupil size, constipation, and decreased gastric, biliary, and
       pancreatic secretions. Pinpoint pupils are a sign of opioid overdose. However, respiratory
       depression is the immediate concern.
       CN: Reduction of risk potential; CL: Analyze

Question 67

67. A client is brought to the emergency department by a friend who states, “He was using a lot of
    heroin until he ran out of money about 2 days ago.” The nurse judges the client to be in opioid
    withdrawal if he exhibits which of the following? Select all that apply.
68. Rhinorrhea.
69. Diaphoresis.
70. Piloerection.
71. Synesthesia.
72. Formication.

Answer 67

67. 1, 2, 3. Symptoms of opioid withdrawal include yawning, rhinorrhea, sweating, chills,
    piloerection (goose bumps), tremors, restlessness, irritability, leg spasms, bone pain, diarrhea, and
    vomiting. Symptoms of withdrawal occur within 36 to 72 hours of usage and subside within a week.
    Withdrawal from heroin is seldom fatal and usually does not necessitate medical intervention.
    Synesthesia (a blending of senses) is associated with lysergic acid diethylamide use, and formication
    (feeling of bugs crawling beneath the skin) is associated with cocaine use.
    CN: Psychosocial integrity; CL: Analyze

Question 68

68. An unconscious client in the emergency department is given IV naloxone (Narcan) due to an
    overdose of heroin. Which of the following would indicate a therapeutic response to the Narcan?Select all that apply.
69. Decreased pulse rate.
70. Warm skin.
71. Dilated pupils.
72. Increased respirations.
73. Consciousness.

Answer 68

68. 4, 5. Naloxone is an opioid antagonist used to treat an opioid overdose. Within a few minutes,
    the client should have an increase of respirations to near normal and become conscious. With a heroin
    overdose, the pulse is not significantly affected, the skin becomes warm and wet, and the pupils are
    dilated. With naloxone the skin would return to a normal temperature and become dry. The pupils also
    would react normally and the pulse would not be decreased.CN: Pharmacological and parenteral therapies; CL: Analyze

Question 69

69. Which of the following should the nurse expect to assess for a client who is exhibiting late
signs of heroin withdrawal?
1. Vomiting and diarrhea.
2. Yawning and diaphoresis.
3. Lacrimation and rhinorrhea.
4. Restlessness and irritability.

Answer 69

69. 1. Vomiting and diarrhea are usually late signs of heroin withdrawal, along with muscle
       spasm, fever, nausea, repetitive sneezing, abdominal cramps, and backache. Early signs of heroin
       withdrawal include yawning, tearing (lacrimation), rhinorrhea, and sweating. Intermediate signs of
       heroin withdrawal are flushing, piloerection, tachycardia, tremor, restlessness, and irritability.
       CN: Reduction of risk potential; CL: Analyze

Question 70

70. After administering naloxone (Narcan), an opioid antagonist, the nurse should monitor the
    client carefully for which of the following?
71. Cerebral edema.
72. Kidney failure.
73. Seizure activity.
74. Respiratory depression.

Answer 70

70. 4. After administering naloxone, the nurse should monitor the client’s respiratory status
       carefully because the drug is short acting and respiratory depression may recur after its effects wear
       off. Cerebral edema, kidney failure, and seizure activity are not directly related to opioid overdose or
       naloxone therapy.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 71

71. When teaching a client who is to receive methadone therapy for opioid addiction, the nurse
    should instruct the client that methadone is useful primarily for which of the following reasons?
72. It is not an addictive substance.
73. A maintenance dose is taken twice a day.
74. The client will no longer be addicted to opioids.
75. The client may work and live normally.

Answer 71

71. 4. The client takes methadone primarily to be able to work, live normally, and function
       productively without the mental and physical deterioration caused by opioid addiction. Methadone
       lessens physiologic dependence on opioids and is used to prevent withdrawal symptoms. Methadone,
       a substance similar to morphine, is an addictive substance; the client is still considered addicted to
       opioids. Because methadone has a long half-life of 15 to 30 hours, it can be taken once a day on an
       outpatient basis.
       CN: Psychosocial integrity; CL: Apply

Question 72

72. A client states to the nurse, “I’m not going to any more Narcotics Anonymous meetings. I felt
    out of place there.” Which of the following responses by the nurse is best?
73. “Try attending a meeting at a different location; you may feel more comfortable there.”
74. “Maybe it just wasn’t a good day for you. Everybody has bad days now and then.”
75. “Perhaps you weren’t paying close enough attention to what they were saying.”
76. “Sometimes the meetings can seem like a waste of time, but you need to attend to stay clean.”

Answer 72

72. 1. Suggesting that the client try attending a meeting at a different location is a supportive,
       positive response and encourages the client to continue participating in treatment. Saying, “Maybe it
       just wasn’t a good day for you,” or “Perhaps you weren’t paying close enough attention,” places blame
       on the client and is not helpful. The statement, “Sometimes the meetings can seem like a waste of
       time, but you need to attend to stay clean,” diminishes the importance of the self-help group and offers
       little support to the client.
       CN: Management of care; CL: Synthesize

Question 73

73. Which of the following should the nurse use as the best measure to determine a client’s
    progress in rehabilitation?
74. The kinds of friends he makes.
    The number of drug-free days he has.
75. The way he gets along with his parents.
76. The amount of responsibility his job entails.

Answer 73

73. 2. The best measure to determine a client’s progress in rehabilitation is the number of drug-
       free days he has. The longer the client abstains, the better the prognosis is. Although the kinds of
       friends the client makes, the way he gets along with his parents, and the degree of responsibility his
       job requires could influence his decision to stay clean, the number of drug-free days is the best
       indicator of progress.
       CN: Physiological adaptation; CL: Evaluate

Question 74

74. Which of the following should lead the nurse to suspect that a client is addicted to heroin?
75. Hilarity.
76. Aggression.
77. Labile mood.
78. Hypoactivity.

Answer 74

74. 4. The client who is addicted to heroin is most likely to exhibit hypoactivity. Initially, the
       client feels euphoric. This is followed by drowsiness, hypoactivity, anorexia, and a decreased sex
       drive. Hilarity, aggression, and a labile mood usually are not associated with heroin addiction.
       CN: Psychosocial integrity; CL: Analyze

Question 75

75. A client brought by ambulance to the emergency department after taking an overdose ofbarbiturates is comatose. The nurse should assess the client for:
76. Kidney failure.
77. Cerebrovascular accident.
78. Status epilepticus.
79. Respiratory failure.

Answer 75

75. 4. Because barbiturates are central nervous system depressants, the nurse should be especially
       alert for the possibility of respiratory failure. Respiratory failure is the most likely cause of death
       from barbiturate overdose. Kidney failure, cerebrovascular accident, and status epilepticus are not
       associated with barbiturate overdose.
       CN: Reduction of risk potential; CL: Analyze

Question 76

76. The client’s friend reports that the client has been taking about eight “reds” (800 mg of
    secobarbital [Seconal]) daily, besides drinking more alcohol than usual. The client’s friend asks
    anxiously, “Do you think she will live?” Which of the following responses by the nurse is most
    appropriate?
77. “We can only wait and see. It’s too soon to tell.”
78. “Do you know her well? She’s so young.”
79. “She is very ill and may not live. Some don’t pull through.”
80. “Her condition is serious. You sound very worried about her.”

Answer 76

76. 4. When a friend asks whether a seriously ill client will live, it is best for the nurse to respond
       by explaining the seriousness of the client’s condition and acknowledging the friend’s concern. This
       type of comment does not offer false hope. Telling the friend to wait and see and that it is too soon to
       tell is a stereotypical statement that offers no support to the friend. Asking the friend to describe his
       or her relationship with the client ignores the friend’s concern and does not focus on the problem.
       Simply saying that the client is very ill and may not live and that some don’t pull through is harsh and
       not supportive.
       CN: Psychosocial integrity; CL: Synthesize

Question 77

77. Before his hospitalization, a client needed increasingly larger doses of barbiturates to
    achieve the same euphoric effect he initially realized from their use. From this information, the nurse
    develops a plan of care that takes into account that the client is likely suffering from which of the
    following?
78. Tolerance.
79. Addiction.
80. Abuse.
81. Dependence

Answer 77

77. 1. Tolerance for a drug occurs when a client requires increasingly larger doses to obtain the
       desired effect. Therefore, the plan of care would address the client’s state of tolerance. The term
       addiction refers to psychological and physiologic symptoms indicating that an individual cannot
       control his or her use of psychoactive substances. This term has been replaced with the term
       dependence. Abuse refers to the excessive use of a substance that differs from societal norms. Drug
       dependence occurs when the client must take a usual or increasing amount of the drug to prevent the
       onset of abstinence symptoms, cannot keep drug intake under control, and continues to use even
       though physical, social, and emotional processes are compromised.
       CN: Physiological adaptation; CL: Analyze

Question 78

78. Which of the following statements by the nurse is most appropriate when addressing a client
    with a barbiturate overdose who awakens in a confused state and exhibits stable vital signs?
79. “I’m here to help you beat your drug habit. But it’s you who will need to work hard.”
80. “It’s time to get straight and stay clean and put an end to your torture.”
81. “I’m glad you pulled through; it was touch and go with you for a while.”
82. “You’re in the hospital because of a drug problem; I’m one of the nurses who will help you.”

Answer 78

78. 4. For a client who is confused when awakening after taking a large dose of barbiturates, the
       nurse should speak in concrete terms using simple statements in a calm, nonjudgmental, gentle manner
       to assist the client with cognitive-perceptual impairment, enhance understanding, and decrease
       anxiety. The other statements contain abstract information and some slang terms that may further
       confuse the client and thus increase the client’s anxiety.
       CN: Psychosocial integrity; CL: Synthesize

Question 79

79. A client states that her “life has gone down the tubes” since her divorce 6 months ago. Then,
    after she lost her job and apartment, she took an overdose of barbiturates so she “could go to sleep
    and never wake up.” Which of the following statements by the nurse should be made first?
80. “It seems as if your self-esteem has been affected by all your losses.”
81. “I know you took an overdose of barbiturates. Are you thinking of suicide now?”
82. “Helplessness is common after losing a job. Are you having trouble making decisions?”
83. “You sound hopeless about the future since your divorce.”

Answer 79

79. 2. The highest priority is assessing for suicide risk. When the client is safe, then the self-
       esteem, helplessness, and hopelessness issues can be addressed.
       CN: Psychosocial integrity; CL: Synthesize

Question 80

80. A client who has experienced the loss of her husband through divorce, the loss of her job and
    apartment, and the development of drug dependency is suffering situational low self-esteem. Which of
    the following outcomes is most appropriate initially?
81. The client will discuss her feelings related to her losses.
82. The client will identify two positive qualities.
83. The client will explore her strengths.
84. The client will prioritize problems.

Answer 80

80. 1. The most appropriate initial outcome for the client is to discuss thoughts and feelings
       related to her losses. The nurse should help the client identify and verbalize her feelings so that she
       can externalize her thoughts and emotions and begin to deal with them. This prevents the client from
       internalizing feelings, which leads to depression and self-harm. The ability to identify two positive
       qualities, explore strengths, and prioritize problems would be appropriate after the client has
       explored her thoughts and feelings, gained awareness of the issues, and then can participate in the
       treatment plan.
       CN: Psychosocial integrity; CL: Evaluate

Question 81

81. The nurse notices that a client recovering from a barbiturate overdose spends most of his timewith other young adults who have substance-related problems. This group of clients is a dominant
    force on the unit, keeping the nondrug users entertained with stories of their “highs.” Which of the
    following methods is best to use when dealing with this problem?
82. Providing additional recreation.
83. Breaking up drug-oriented discussions.
84. Speaking with the clients individually about their behavior.
85. Discussing the behavior at the daily community meeting.

Answer 81

81. 4. The best method to deal with the problem is to discuss observations with clients at the
       daily community meeting because the problem involves all of the clients and this provides them with
       the opportunity to offer their views. Peer pressure is valuable in confronting self-defeating and
       destructive behaviors. Providing additional recreation avoids or ignores the problem and is damaging
       to all clients because it decreases trust in the nurse. Breaking up drug-oriented discussions would not
       be sufficient to stop the behavior. Speaking with the clients individually about their behavior is not as
       effective as dealing with the problem openly and directly with everyone.CN: Psychosocial integrity; CL: Synthesize

Question 82

82. A client recovering from a drug overdose is interacting with the nurse and recounting her
    exploits at numerous parties she’s attended. Which of the following actions is most therapeutic?
83. Allowing the client to continue with her stories.
84. Telling the client you’ve heard the stories before.
85. Questioning the client further about her exploits.
86. Directing the conversation to realistic concerns.

Answer 82

82. 4. The nurse directs the conversation to realistic concerns or issues to decrease denial and
       focus on rebuilding a substance-free life. Allowing the client to continue with the stories or
       questioning the client further about her exploits reinforces the denial. Telling the client you’ve heard
       the stories before is nondirective. Additionally, these actions do nothing to help the client focus on
       rebuilding a substance-free life.
       CN: Psychosocial integrity; CL: Synthesize

Question 83

83. The nurse is speaking to a sixth grade class about drugs. A student states, “I know someone
    who smokes marijuana and he says it’s safe.” The nurse should tell the student:
84. “Marijuana isn’t safe, and it is illegal.”
85. “Do you really believe him?”
86. “That drug causes more damage to your body than regular cigarettes.”
87. “Marijuana usage can lead to using other chemicals.”

Answer 83

83. 3. The statement that marijuana causes more damage to your body than regular cigarettes is a
       direct, correct, educational response to the student’s statement that does not decrease the student’s or
       the friend’s self-worth. Marijuana causes harmful pulmonary effects, weakens heart contractions,
       causes immunosuppression, and reduces serum testosterone and sperm count. Telling the student that
       marijuana is unsafe and illegal, or that using marijuana leads to using other chemicals, does not
       provide the student with factual information to answer the student’s question. Asking whether the
       student really believes the friend challenges the student and may lead to defensive behavior.
       CN: Psychosocial integrity; CL: Apply

Question 84

84. When developing a teaching plan for a group of middle school children about the drug 3,4-
    methylenedioxymethamphetamine (Ecstasy), what information should the nurse expect to include?
    Select all that apply.
85. Using Ecstasy is similar to using speed.
86. Ecstasy is used at all-night parties.
87. Teeth grinding is seen with cocaine, not Ecstasy use.
88. It can cause death.
89. It reduces self-consciousness.

Answer 84

84. 1, 2, 4, 5. Ecstasy is chemically related to methamphetamine (speed) and is used at all-night
    parties also known as “raves” to enhance dancing, closeness to others, affection, and the ability to
    communicate. Euphoria, heightened sexuality, disinhibition, and diminished self-consciousness can
    occur. Adverse effects include tachycardia, elevated blood pressure, anorexia, dry mouth, and teeth
    grinding. Pacifiers, including candy-shaped pacifiers and lollipops, are used to ease the discomfort
    associated with teeth grinding and jaw clenching. Hyperthermia, dehydration, renal failure, and death
    can occur.
    CN: Reduction of risk potential; CL: Create

Question 85

85. A young client is being admitted to the psychiatric unit after her obstetrician’s staff suspected
    she was experiencing a postpartum psychosis. Her husband said she was doing fine for 2 weeks after
    the birth of the baby, except for pain from the C-section and trouble sleeping. These symptoms
    subsided over the next 4 weeks. Then 3 days ago, the client started having anxiety, irritability,
    vomiting, diarrhea, and delirium, resulting in her inability to care for the baby. Then the husband says,
    “I saw that my bottles of alprazolam and oxycodone were empty even though I haven’t been taking
    them.” In what order of priority from first to last should the nurse do the following?
86. Call the physician for prescriptions for appropriate treatment for opiate and benzodiazepine
    withdrawal.
87. Immediately place the client on withdrawal precautions.
88. Confirm with the client that she has in fact been using her husband’s medications.4. Assess the client for prior and current use of any other substances.

Answer 85

85.
3. Confirm with the client that she has in fact been using her husband’s medications.
4. Assess the client for prior and current use of any other substances.
2. Immediately place the client on withdrawal precautions.
1. Call the physician for prescriptions for appropriate treatment for opiate and benzodiazepine
withdrawal.
It crucial to confirm that the client was taking her husband’s opiates and benzodiazepines and that
her symptoms are due to the sudden withdrawal from these medications. It is also important to know
if she has been using other substances (such as alcohol) that may cause other withdrawal symptoms.
Even before calling the physician for prescriptions, the nurse can initiate withdrawal precautions for
client safety.CN: Safety and infection control; CL: Apply

Question 86

Department for an overdose of Percocet (oxycontin). Her son calls the unit and expresses intense
anger that his mother is being treated as a “common street addict.” He says she has severe back pain
and was given that prescription by her doctor. “She just accidentally took a few too many pills last
night.” Which reply by the nurse is most therapeutic?
1. “I understand that your mother may not have intentionally taken too many pills. This medication
can cause one to forget how many have been taken.”
2. “It may be appropriate for your mother to be referred to a pain management program.”
3. “Unfortunately, it is fairly common for clients with pain to increase their use of pain pills over
time.”
4. “I can hear how upset you are. You sound very concerned about your mother.”

Answer 86

86. 4. Acknowledging the client’s son’s feelings is the most therapeutic intervention because he is
       not likely to hear the nurse’s information until his anger and other feelings are addressed and subside.
       Then it is important to acknowledge that oxycontin, especially in older clients, can interfere with
       remembering how many pills were taken. It is common for clients with chronic pain to inadvertently
       overuse or become addicted to pain medications. Pain management programs help clients to
       withdraw from the offending medication and start on a multifaceted system for controlling the pain.
       CN: Psychosocial integrity; CL: Create

Question 87

87. A client is being admitted to the addictions unit for a confirmed and long-term addiction to
    Xanax (alprazolam). She continues to strongly deny her addiction, stating she was prescribed the
    Xanax to control her “panic attacks.” Which of the following procedures would be the most important
    during the admission process? Select all that apply.
88. Assess the client for suicide, escape, and aggression risks.
89. With the client present, search the client’s clothes and belongings for contraband and restricted items.
90. Initiate withdrawal precautions.
91. Explain the unit routine and types of groups.
92. Obtain a urine specimen for a urine drug screen.

Answer 87

87. 1, 2, 3, 5. Clients who deny an addiction and the need for treatment can be at risk for a suicide
    attempt, efforts to escape the unit, and aggression directed at staff. A contraband search is a safety
    measure to look for concealed drugs and dangerous items. Depending on the last use of the substance,
    withdrawal symptoms can begin quickly. A urine drug screen is crucial to determine what other
    substances the client may be using that may cause other withdrawal symptoms. Explaining the unit
    routines and groups can wait until the client is calmer and more receptive.
    CN: Safety and infection control; CL: Analyze

Question 88

88. A client is returning to the primary care physician’s office for follow-up on his diagnosis of
    coronary artery disease. After all the appropriate exams and assessments are completed, the nurse
    asks the client about how well he is sleeping. The client states, “Oh, that’s not a problem anymore. I
    take a couple of my wife’s Valiums (diazepam) and sleep like a baby.” Which of the following
    information should the nurse obtain? Select all that apply.
89. The reason the client’s wife is taking Valium.
90. The dose of the Valium he is taking and how long he has been taking it.
91. Exactly how many Valiums he takes at night and during the day,
92. Whether he intends to stop the Valium use.
93. What was interfering with his sleep prior to starting the Valium.

Answer 88

88. 2, 3, 5. The dose, length of use, and the number of Valiums taken per day are important for
    assessing the severity of the substance abuse and potential withdrawal. Determining sleep
    interferences is necessary for treating the underlying causes of the insomnia. The reason his wife
    takes Valium is confidential information and not critical to his situation. Getting off the Valium is
    essential, not an option, especially with his cardiac issues. This needs to be done safely if he has
    been taking it for more than a week or 2.
    CN: Psychosocial integrity; CL: Analyze

Question 89

89. A client who chronically snorts cocaine is brought to the emergency department due to a
    cocaine overdose. The client is experiencing delusions, hallucinations, mild respiratory distress, and
    mild tachycardia initially. The nurse should do which of the following? Select all that apply.
90. Induce vomiting.
91. Place seizure pads on the bed.
92. Administer PRN haloperidol (Haldol) as prescribed.
93. Monitor for respiratory acidosis.
94. Encourage deep breathing.
95. Monitor for metabolic acidosis.

Answer 89

89. 2, 3, 4, 5, 6. The cocaine was not swallowed, so inducing vomiting is not indicated. A
    cocaine overdose can produce seizures, paranoia, and respiratory and/or metabolic acidosis. Deep
    breathing will help decrease the respiratory distress and pulse rate.
    CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 90

90. A client walks into the clinic and tells the nurse she has run out of money for crack, has
    crashed, and wants something to help her feel better. Which of the following is most important for the
    nurse to assess?
91. Suspiciousness.
92. Loss of appetite.
93. Drug craving.
94. Suicidal ideation.

Answer 90

90. 4. The nurse assesses the client for feelings of depression and suicidal ideation. After
       experiencing an instantaneous high from crack, a crash immediately follows and the client has an
       intense craving for more crack. A crash commonly leads to a cocaine-induced depression when
       additional crack is unavailable. At times, the depression is so severe that users attempt suicide.
       Although suspiciousness, loss of appetite, and drug craving are also associated with cocaine use, they
       are less of a priority than suicidal ideation.
       CN: Psychosocial integrity; CL: Analyze

Question 91

91. A client in the emergency department is diagnosed as having amphetamine psychosis. The
    nurse should take all of the following actions in which order of priority from first to last?
92. Transfer the client to the psychiatric unit.
93. Monitor cardiac and respiratory status.
94. Place seizure pads on the bed.
95. Administer IM haloperidol (Haldol) as prescribed

Answer 91

91.
3. Place seizure pads on the bed.
2. Monitor cardiac and respiratory status.4. Administer IM haloperidol (Haldol) as prescribed.
1. Transfer the client to the psychiatric unit.
The risk of seizures is an immediate safety issue, and the nurse should first place seizure pads on
the bed. Amphetamine overdose can produce cardiac arrhythmias and respiratory collapse; the nurse
should next monitor the client. Then the Haldol is indicated to antagonize the amphetamine affects.
When the client is medically stable, the nurse can transfer the client to a psychiatric unit. Haldol
would be stopped as the psychotic symptoms subside.
CN: Reduction of risk potential; CL: Synthesize

Question 92

92. A client has been taking increased amounts of alprazolam (Xanax) for about 6 months for
    anxiety. She asks the nurse how she can “get off the Xanax.” The most accurate answer by the nurse is
    which of the following?
93. “There will be an immediate discontinuation of the Xanax and haloperidol (Haldol) will be
    available if needed.”
94. “Instead of Xanax, you will take lorazepam (Ativan) in decreasing doses and frequency over a
    period of 3 to 4 days.”
95. “The Xanax will be tapered down over a period of 48 hours.”
96. “Xanax will be available on an as-needed basis for 4 to 5 days.”

Answer 92

92. 2. Ativan, as opposed to Xanax, is available in dosage ranges that allow more gradual
       tapering down of doses over the 3 to 4 days. Haldol is not effective for benzodiazepine withdrawal.
       Tapering Xanax in 48 hours is too rapid. Offering Xanax as a PRN does not deal with the need to
       gradually reduce the dose and frequency over time.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 93

93. The client is fidgeting and has trouble sitting still. He has difficulty concentrating and is
    tangential. Which of the following interventions should help decrease this client’s level of anxiety?
    Select all that apply.
94. Refocusing attention.
95. Allowing ventilation.
96. Suggesting a time-out.
97. Giving intramuscular medication.
98. Assisting with problem solving.

Answer 93

93. 1, 2, 5. The client is exhibiting symptoms of moderate anxiety. At this level of anxiety, the
    nurse should help the client to decrease anxiety by allowing ventilation, crying, exercise, and
    relaxation techniques. The nurse would further assist the client by refocusing his attention, relating
    behaviors and feelings to anxiety, and then assisting with problem solving. Oral medication may be
    needed if the client’s anxiety is prolonged or does not decrease with the nurse’s interventions.
    Suggesting a time-out and giving intramuscular medication are possible interventions for a client
    whose anxiety level is severe.
    CN: Psychosocial integrity; CL: Synthesize

Question 94

94. When caring for a client who has overdosed on phencyclidine (PCP), the nurse should be
    especially cautious about which of the following client behaviors?
95. Visual hallucinations.
96. Violent behavior.
97. Bizarre behavior.
98. Loud screaming.

Answer 94

94. 2. The nurse must be especially cautious when providing care to a client who has taken
       phencyclidine (PCP) because of unpredictable, violent behavior. The client can appear to be in a
       calm state or even in a coma, then become violent, and then return to a calm or comatose state. Visual
       hallucinations, bizarre behavior, and loud screaming are associated with PCP-intoxicated clients.
       However, the unpredictable, violent behavior presents a major issue of safety for clients and staff.
       CN: Safety and infection control; CL: Analyze

Question 95

95. Which of the following liquids should the nurse administer to a client who is intoxicated on
    phencyclidine (PCP) to hasten excretion of the chemical?
96. Water.
97. Milk.
98. Cranberry juice.
99. Grape juice.

Answer 95

95. 3. An acid environment aids in the excretion of PCP. Therefore, the nurse should give the
       client with PCP intoxication cranberry juice to acidify the urine to a pH of 5.5 and accelerate
       excretion.
       CN: Reduction of risk potential; CL: Synthesize

Question 96

96. When assessing a client with possible alcohol poisoning, the nurse should investigate the
    client’s use of which of the following substances while drinking alcohol?
97. Marijuana.
98. Lysergic acid diethylamide.
99. Peyote.
100. Psilocybin.

Answer 96

96. 1. Smoking marijuana while using alcohol can lead to alcohol poisoning because marijuana
       masks the nausea and vomiting associated with excessive alcohol consumption. Marijuana contains
       tetrahydrocannabinol (THC), which is responsible for suppressing nausea. With dangerous levels of
       alcohol in the body, respiratory depression, coma, and death can occur. Lysergic acid diethylamide,
       peyote, and psilocybin do not contain THC.
       CN: Reduction of risk potential; CL: Analyze

Question 97

97. A client with a cocaine dependency is irritable, anxious, highly sensitive to stimuli, and
    overreactive to clients and staff on the unit. Which of the following actions is most therapeutic for
    this client?
98. Secluding and restraining the client as needed.
99. Telling the client to stay in his room until he can control himself.
100. Providing the client with frequent “time-outs.”
101. Confronting the client about his behaviors.

Answer 97

97. 3. Providing frequent “time-outs” when the client is highly anxious, sensitive, irritable, andover-reactive is needed to calm the client and reduce the possibility of escalating behaviors and
       violence. Secluding and restraining the client is not appropriate and would only be used if the client
       was threatening others and other alternative actions had been unsuccessful. Telling the client to stay in
       his room until he can control himself is unrealistic and futile because the client cannot eliminate
       behaviors induced by chemicals. Confronting the client about his behaviors would most likely lead to
       aggression and possibly violent behavior.
       CN: Safety and infection control; CL: Synthesize

Question 98

98. A client with symptoms of amphetamine psychosis that are improving is anxious and still
    experiencing some delusions. When developing the client’s plan of care, which of the following
    measures should the nurse include?
99. Assign the client to a group meeting about the physiologic effects of drugs.
100. Advise the client to watch television.
101. Wait for the client to approach the nurse.
102. Invite the client to play a game of ping-pong with the nurse.

Answer 98

98. 4. The nurse should invite the client who is anxious to participate in an activity that involves
       gross motor movements. Doing so helps to direct energy toward a therapeutic activity. Appropriate
       activities include walking, riding a stationary bicycle, or playing volleyball. Assigning the client to
       an educational group is not helpful because the anxious client would be unable to sit in a group setting
       and concentrate on what was occurring in the group. Watching television may be too stimulating for
       the client, possibly increasing anxiety. Additionally, the client may be too anxious to sit and focus.
       Waiting for the client to approach the nurse is not helpful or appropriate. The nurse is responsible for
       initiating contact with the client.
       CN: Psychosocial integrity; CL: Create

Question 99

99. In consultation with his outpatient psychiatrist, a client is admitted for detoxification from
    methadone. He states, “I got addicted to morphine for my chronic knee pain. Methadone worked for a
    long time. Since I had my knee replacement surgery 3 months ago and physical therapy, I don’t think I
    need methadone any more.” It is important to discuss which of the following pieces of information
    with this client? Select all that apply.
100. “Detoxification will likely occur with slowly decreasing doses of methadone.”
101. “Oxycodone will be available if needed for break-through-pain.”
102. “You will be monitored closely for withdrawal symptoms and treated as needed.”
103. “Physical therapy and nonchemical pain management techniques can be prescribed if needed.”
104. “If you have knee stiffness or pain, it is likely to be managed by nonnarcotic pain medicines.”

Answer 99

99. 1, 3, 4, 5. Since methadone is an addictive medication, the client will be gradually tapered off
    of it, while monitoring him for withdrawal symptoms. Any residual pain is likely to be controlled
    with other pain management techniques and nonnarcotic pain medication. It is very unlikely that
    oxycodone would be prescribed PRN since it is a very addictive medication.
    CN: Reduction of risk potential; CL: Apply

Question 100

100. A client approaches the medication nurse and states, “I can’t believe you are NOT helping
     me with my cravings for my fentanyl patches! When I got off alcohol 2 years ago, they gave me
     naltrexone for my cravings, and it really helped. I can’t stand the cravings and back pain anymore, and
     I’m getting angry.” Which of the following responses by the nurse would be helpful for this client?
     Select all that apply.
     “Naltrexone does help decrease the cravings for alcohol.”
     “Naltrexone can interfere with opiate cravings in some clients.”
     “Cravings are hard to deal with, especially when you are in pain too.”
     “I hear your frustration about how your detoxification is going.”
101. “I am positive naltrexone can help with your cravings for fentanyl.”
     “I can ask your physician if he thinks naltrexone might help you.”

Answer 100

100. 1, 2, 3, 4, 6. Acknowledgment of the client’s frustration, pain, and cravings is important to
     decrease the client’s anger. Naltrexone can help with detoxification from alcohol and opiates. Asking
     the physician about the possibility of adding naltrexone is appropriate. The nurse can never promise
     that a medication will help this client, since naltrexone is effective with only 20% to 30% of clients
     with opiate cravings.
     CN: Pharmacological and parental therapies; CL: Analyze

Question 101

The Client with Anxiety Disorders and Anxiety-
Related Disorders
101. A 17-year-old female client who has been treated for an anxiety disorder since middle
school with behavioral treatment and as-needed (PRN) anxiety medication is preparing to go to
college. The parents are concerned that she will experience an exacerbation of symptoms if she
attends college out of town and want the daughter to attend the local community college and live at
home. The girl believes she can handle the challenge of leaving home for college. How should the
nurse in the outpatient clinic respond to the family’s concerns?
1. “Your parents have a point; transitions have been hard for you in the past.”
2. “There are many pros and cons here that we all need to discuss together.”
3. “Every high school graduate deserves the chance to take on new challenges.”
4. “It may be premature for you to think of college at this point in time.”

Answer 101

The Client with Anxiety Disorders and Anxiety-Related
Disorders
101. 2. The nurse cannot appear to take the side of either the student or her mother, so discussing
the situation together where all points of view can be presented and evaluated is the best option. To
avoid college altogether is likely to only escalate both parties’ anxiety.
CN: Psychosocial integrity; CL: Apply

Question 102

102. A 16-year-old boy who is academically gifted is about to graduate from high school early
     since he has completed all courses needed to earn a diploma. Within the last 3 months he has begun to
     experience panic attacks that have forced him to leave classes early and occasionally miss a day of
     school. He is concerned that these attacks may hinder his ability to pursue a college degree. What
     would be the best response by the school nurse who has been helping him deal with his panic attacks?
103. “It is natural to be worried about going into a new environment. I am sure with your abilities
     you will do well once you get settled.”
104. “You are putting too much pressure on yourself. You just need to relax more and things will be
     alright.”
105. “It might be best for you to postpone going to college. You need to get these panic attacks
     controlled first.”
106. “It sounds like you have real concern about transitioning to college. I can refer you to a health care
     provider for assessment and treatment.”

Answer 102

102. 4. The client’s concerns are real and serious enough to warrant assessment by a physician
        rather than being dismissed as trivial. Though he is very intelligent, his intelligence cannot overcome
        his anxiety, and in fact, his anxiety is likely to interfere with his ability to perform in college if no
        assessment and treatment is received. Just postponing college is likely to increase the client’s anxiety
        rather than lower it since it does not address the panic he is experiencing.
        CN: Psychosocial integrity; CL: Analyze

Question 103

103. A client has been diagnosed with posttraumatic stress disorder (PTSD) because he
     experienced childhood sexual abuse (CSA) by his babysitter and her boyfriend from ages 4 to 10. He
     is admitted for the second time after physically assaulting a woman he said was a prostitute. “She is
     no better than my babysitter and deserves to be dead. I’d like to kill the sitter too.” With the
     knowledge of PTSD and CSA, which of the following nursing interventions should be implemented at
     admission? Select all that apply.
104. Institute precautions for suicide, assault, and escape.
105. Ask him to sign a no harm contract.
106. Provide safe outlets for his anger and rage.
107. Encourage him to express his attitude toward prostitutes during unit group sessions.
108. In one-to-one staff talks, encourage him to safely verbalize his anger toward his babysitter and her
     boyfriend.

Answer 103

103. 1, 2, 3, 5. Anger and rage could be directed at self and others. He implies that he did nothingwrong in assaulting the woman (denial) and may try to leave without treatment. A No Harm Contract
     is essential for everyone’s safety. He needs safe outlets, including staff talks, for his anger. Talking
     about his views of prostitutes in unit groups may be upsetting to female clients who have sexual abuse
     issues as well, so this needs to occur in private.
     CN: Safety and infection control; CL: Create

Question 104

104. A client is taking diazepam (Valium) for generalized anxiety disorder. Which instruction
     should the nurse give to this client? Select all that apply.
105. To consult with his health care provider before he stops taking the drug.
106. To avoid eating cheese and other tyramine-rich foods.
107. To take the medication on an empty stomach.
108. Not to use alcohol while taking the drug.
109. To stop taking the drug if he experiences swelling of the lips and face and difficulty breathing.

Answer 104

104. 1, 4, 5. The nurse should instruct the client who is taking diazepam to take the medication as
     prescribed; stopping the medication suddenly can cause withdrawal symptoms. This medication is
     used for a short term only. The drug dose can be potentiated by alcohol and the client should not drink
     alcoholic beverages while taking this drug. Swelling of the lips and face and difficulty breathing are
     signs and symptoms of an allergic reaction. The client should stop taking the drug and seek medical
     assistance immediately. The client does not need to avoid eating foods containing tyramine; tyramine
     interacts with monoamine oxidase inhibitors, not Valium. The client can take the medication with
     food.
     CN: Health promotion and maintenance; CL: Synthesize

Question 105

105. An adult client diagnosed with anxiety disorder becomes anxious when she touches fruits
     and vegetables. What should the nurse do?
106. Instruct the woman to avoid touching these foods.
107. Ask the woman why she becomes anxious in these situations.
108. Assist the woman to make a plan for her family to do the food shopping and preparation.
109. Teach the woman to use cognitive behavioral approaches to manage her anxiety.

Answer 105

105. 4. Cognitive behavioral therapy is effective in treating anxiety disorders. The nurse can
        assist the client in identifying the onset of the fears that cause the anxiety and develop strategies to
        modify the behavior associated with the fears. Avoiding touching foods, asking about reasons for the
        anxiety, and providing ways to work around touching the foods do not deal with the anxiety and are
        not interventions that will help this client.
        CN: Psychosocial integrity; CL: Synthesize

Question 106

106. A client who is pacing and wringing his hands states, “I just need to walk” when questioned
     by the nurse about what he is feeling. Which of the following responses by the nurse is most
     therapeutic?
107. “You need to sit down and relax.”
108. “Are you feeling anxious?”
109. “Is something bothering you?”
110. “You must be experiencing a problem now.”

Answer 106

106. 2. Asking, “Are you feeling anxious?” helps the client to specifically label the feeling as
        anxiety so that he can begin to understand and manage it. Some clients need assistance with
        identifying what they are feeling so they can recognize what is happening to them. Stating, “You need
        to sit down and relax,” is not appropriate because the client needs to continue his pacing to feel
        better. Asking if something is bothering the client or saying that he must be experiencing a problem is
        vague and does not help the client identify his feelings as anxiety.
        CN: Psychosocial integrity; CL: Synthesize

Question 107

107. A client brought to the emergency department is perspiring profusely, breathing rapidly, and
     having dizziness and palpitations. Problems of a cardiovascular nature are ruled out, and the client’s
     diagnosis is tentatively listed as a panic attack. After the symptoms pass, the client states, “I thought I
     was going to die.” Which of the following responses by the nurse is best?
108. “It was very frightening for you.”
109. “We would not have let you die.”
110. “I would have felt the same way.”
111. “But you’re okay now.”

Answer 107

107. 1. The nurse responds with the statement, “It was very frightening for you,” to express
        empathy, thus acknowledging the client’s discomfort and accepting his feelings. The nurse conveys
        respect and validates the client’s self-worth. The other statements do not focus on the client’s
        underlying feelings, convey active listening, or promote trust.
        CN: Psychosocial integrity; CL: Synthesize

Question 108

108. A client commonly jumps when spoken to and reports feeling uneasy. The client says, “It’s
     as though something bad is going to happen.” In which order from first to last should the following
     nursing actions be done?
109. Teach problem-solving strategies.
110. Ask the client to deep breathe for 2 minutes.
111. Discuss the client’s feelings in more depth.
112. Reduce environmental stimuli.

Answer 108

108.
4. Reduce environmental stimuli.
2. Ask the client to deep breathe for 2 minutes.
3. Discuss the client’s feelings in more depth.1. Teach problem-solving strategies.
Immediate anxiety-reducing strategies are to decrease stimuli and then do deep breathing. Once
the anxiety is lessened, then the client’s feelings can be explored for triggers and underlying issues.
Then problem-solving strategies can be discussed to handle the triggers and issues appropriately.
CN: Psychosocial integrity; CL: Synthesize

Question 109

109. Which of the following points should the nurse include when teaching a client about panic
     disorder?
110. Staying in the house will eliminate panic attacks.
111. Medication should be taken when symptoms start.
112. Symptoms of a panic attack are time limited and will abate.
113. Maintaining self-control will decrease symptoms of panic.

Answer 109

109. 3. It is important for the nurse to teach the client that the symptoms of a panic attack are time
        limited and will abate. This helps decrease the client’s fear about what is occurring. Clients benefit
        from learning about their illness, what symptoms to expect, and the helpful use of medication. A
        simple biologic explanation of the disorder can convince clients to take their medication. Telling the
        client to stay in the house to eliminate panic attacks is not correct or helpful. Panic attacks can occur
        “out of the blue,” and clients with panic disorder can become agoraphobic because of fear of having a
        panic attack where help is not available or escape is impossible. Medication should be taken on a
        scheduled basis to block the symptoms of panic before they start. Taking medication when symptoms
        start is not helpful. Telling the client to maintain self-control to decrease symptoms of panic is false
        information because the brain and biochemicals may account for its development. Therefore, the
        client cannot control when a panic attack will occur.
        CN: Psychosocial integrity; CL: Create

Question 110

110. A client with panic disorder is taking alprazolam (Xanax) 1 mg PO three times daily. The
     nurse understands that this medication is effective in blocking the symptoms of panic because of its
     specific action on which of the following neurotransmitters?
111. Gamma-aminobutyrate.
112. Serotonin.
113. Dopamine.
114. Norepinephrine.

Answer 110

110. 1. Alprazolam, a benzodiazepine used on a short-term or temporary basis to treat symptoms
        of anxiety, increases gamma-aminobutyrate, a major inhibitory neurotransmitter. Because gamma-
        aminobutyric acid is increased and the reticular activating system is depressed, incoming stimuli are
        muted and the effects of anxiety are blocked. Alprazolam does not directly target serotonin,
        dopamine, or norepinephrine.
        CN: Pharmacological and parenteral therapies; CL: Apply

Question 111

111. A client is diagnosed with generalized anxiety disorder (GAD) and given a prescription for
     venlafaxine (Effexor). Which of the following information should the nurse include in a teaching plan
     for this client? Select all that apply.
112. Various strategies for reducing anxiety.
113. The benefits and mechanisms of actions of Effexor in treating GAD.
114. How Effexor will eliminate his anxiety at home and work.
115. The management of the common side effects of Effexor.
116. Substituting adaptive coping strategies for maladaptive ones.
117. The positive effects of Effexor being evident in 4 to 5 days.

Answer 111

111. 1, 2, 4, 5. It is appropriate to provide education on medication mechanisms, benefits, and
     managing side effects. No medication will eliminate all anxiety, so teaching about anxiety reduction
     and adaptive coping is needed. Effexor is a serotonin-norepinephrine reuptake inhibitor
     antidepressant and it will take 2 to 4 weeks to feel the effects.
     CN: Pharmacological and parenteral therapies; CL: Create

Question 112

112. While a client is taking alprazolam (Xanax), which of the following should the nurse instruct
the client to avoid?
1. Chocolate.
2. Cheese.
3. Alcohol.
4. Shellfish.

Answer 112

112. 3. Using alcohol or any central nervous system depressant while taking a benzodiazepine,
        such as alprazolam, is contraindicated because of additive depressant effects. Ingestion of chocolate,
        cheese, or shellfish is not problematic.
        CN: Pharmacological and parenteral therapies; CL: Apply

Question 113

113. Which of the following statements by a client who has been taking buspirone (BuSpar) as
     prescribed for 2 days indicates the need for further teaching?
114. “This medication will help my tight, aching muscles.”
115. “I may not feel better for 7 to 10 days.”
116. “The drug does not cause physical dependence.”
117. “I can take the medication with food.”

Answer 113

113. 1. Buspirone, a nonbenzodiazepine anxiolytic, is particularly effective in treating the
        cognitive symptoms of anxiety, such as worry, apprehension, difficulty with concentration, and
        irritability. BuSpar is not effective for the somatic symptoms of anxiety (muscle tension). Therapeutic
        effects may be experienced in 7 to 10 days, with full effects not occurring for 3 to 4 weeks. This drug
        is not known to cause physical or psychological dependence. It can be taken with food or small meals
        to reduce gastrointestinal upset.
        CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 114

114. A week ago, a tornado destroyed the client’s home and seriously injured her husband. The
     client has been walking around the hospital in a daze without any outward display of emotions. She
     tells the nurse that she feels like she’s going crazy. Which of the following actions should the nurse
     use first?
115. Explain the effects of stress on the mind and body.
116. Reassure the client that her feelings are typical reactions to serious trauma.
117. Reassure the client that her symptoms are temporary.
118. Acknowledge the unfairness of the client’s situation.

Answer 114

114. 2. The nurse initially reassures the client that her feelings and behaviors are typical reactions
        to serious trauma to help decrease anxiety and maintain self-esteem. Explaining the effects of stress
        on the body may be helpful later. Telling the client that her symptoms are temporary is less helpful.
        Acknowledging the unfairness of the client’s situation does not address the client’s needs at this time.
        CN: Psychosocial integrity; CL: Synthesize

Question 115

115. After being discharged from the hospital with acute stress disorder, a client is referred to the
     outpatient clinic for follow-up. Which of the following is most important for the client to use for
     continued alleviation of anxiety?
116. Recognizing when she is feeling anxious.
117. Understanding reasons for her anxiety.
118. Using adaptive and palliative methods to reduce anxiety.
119. Describing the situations preceding her feelings of anxiety.

Answer 115

115. 3. The client with anxiety may be able to learn to recognize when she is feeling anxious,
        understand the reasons for her anxiety, and be able to describe situations that preceded her feelings of
        anxiety. However, she is likely to continue to experience symptoms unless she has also learned to use
        adaptive and palliative methods to reduce anxiety.
        CN: Psychosocial integrity; CL: Synthesize

Question 116

116. A client with acute stress disorder states to the nurse, “I keep having horrible nightmares
     about the car accident that killed my daughter. I shouldn’t have taken her with me to the store.” Which
     of the following responses by the nurse is most therapeutic?
117. “Don’t keep torturing yourself with such horrible thoughts.”
118. “Stop blaming yourself. It’s only hurting you.”
119. “Let’s talk about something that is a bit more pleasant.”
120. “The accident just happened and could not have been predicted.”

Answer 116

116. 4. Saying, “The accident just happened and could not have been predicted,” provides the
        client with an objective perception of the event instead of the client’s perceived role. This type of
        statement reflects active listening and helps to reduce feelings of blame and guilt. Saying, “Don’t keep
        torturing yourself,” or “Stop blaming yourself,” is inappropriate because it tells the client what to do,
        subsequently delaying the therapeutic process. The statement, “Let’s talk about something that is a bit
        more pleasant,” ignores the client’s feelings and changes the subject. The client needs to verbalize
        feelings and decrease feelings of isolation.
        CN: Psychosocial integrity; CL: Synthesize

Question 117

117. The client, a veteran of the Vietnam war who has posttraumatic stress disorder, tells the
     nurse about the horror and mass destruction of war. He states, “I killed all of those people for
     nothing.” Which of the following responses by the nurse is appropriate?
118. “You did what you had to do at that time.”
119. “Maybe you didn’t kill as many people as you think.”
120. “How many people did you kill?”
121. “War is a terrible thing.”

Answer 117

117. 1. The nurse states, “You did what you had to do at that time,” to help the client evaluate past
        behavior in the context of the trauma. Clients commonly feel guilty about past behaviors when
        viewing them in the context of current values. The other statements are inappropriate because they do
        not help the client to evaluate past behavior in the context of the trauma.
        CN: Psychosocial integrity; CL: Synthesize

Question 118

118. A client with acute stress disorder has avoided feelings of anger toward her rapist and
     cannot verbally express them. The nurse suggests which of the following activities to assist the client
     with expressing her feelings?
119. Working on a puzzle.
     Writing in a journal.
120. Meditating.
121. Listening to music.

Answer 118

118. 2. Writing in a journal can help the client safely express feelings, particularly anger, when
        the client cannot verbalize them. Safely externalizing anger by writing in a journal helps the client to
        maintain control over her feelings.
        CN: Psychosocial integrity; CL: Synthesize

Question 119

119. When developing the plan of care for a client with acute stress disorder who lost her sister
     in a boating accident, which of the following should the nurse initiate?
120. Helping the client to evaluate her sister’s behavior.
121. Telling the client to avoid details of the accident.
122. Facilitating progressive review of the accident and its consequences.
123. Postponing discussion of the accident until the client brings it up

Answer 119

119. 3. The nurse should facilitate progressive review of the accident and its consequences to
        help the client integrate feelings and memories and to begin the grieving process. Helping the client to
        evaluate her sister’s behavior, telling the client to avoid details of the accident, or postponing the
        discussion of the accident until the client brings it up is not therapeutic and does not facilitate the
        development of trust in the nurse. Such actions do not facilitate review of the accident, which is
        necessary to help the client integrate feelings and memories and begin the grieving process.
        CN: Management of care; CL: Create

Question 120

120. A soldier on his second tour of dutywas notified of the date that he will be redeployed. As
     this date approaches, he is showing signs of excess anxiety and irritability and inability to sleep at
     night because of nightmares of IED (improvised explosive devices) tragedies, all leading to poor
     work performance. His commanding officer refers him to the base hospital for an evaluation. The
     admitting nurse should take the following actions in order of priority from first to last?
121. Remind him that any feelings and problems he is having are typical in his current situation.
122. Ask him to talk about his upsetting experiences.
123. Remove any weapons and dangerous items he has in his possession.
124. Acknowledge any injustices/unfairness related to his experiences and offer empathy and
     support.

Answer 120

120.
3. Remove any weapons and dangerous items he has in his possession.
1. Remind him that any feelings and problems he is having are typical in his current situation.4. Acknowledge any injustices/unfairness related to his experiences and offer empathy and
support.
2. Ask him to talk about his upsetting experiences.
Safety is the first priority in clients experiencing Acute Stress Disorder (ASD). ASD symptoms
are typical reactions to an abnormal situation that are not being handled effectively. When the client
believes he is “normal,” being accepted, understood, and supported, then he will be able to discuss
his thoughts and feelings related to the traumas of the war.
CN: Safety and infection control; CL: Synthesize

Question 121

121. A newly admitted 20-year-old client, diagnosed with posttraumatic stress disorder (PTSD),
     reluctantly reveals that she escaped from a satanic cult 2 years ago. The mother has been in the cult
     since the client was 3 years old and refused to leave with the client. The client says, “Nobody will
     ever believe the horrible things the men did to me, and my mother never stopped them.” Which of the
     following responses is appropriate for the nurse to make?
122. “I’ll believe anything you tell me. You can trust me.”
123. “I can’t understand why your mother didn’t protect you. It’s not right.”
124. “Tell me about the cult. I didn’t know there were any near here.”
125. “It must be difficult to talk about what happened. I’m willing to listen.”

Answer 121

121. 4. Survivors of trauma/torture have a lot of difficulty with trust and do not readily talk about
        the horrible events. Therefore, empathy and a willingness to listen without pressuring the client are
        crucial. Option 1 may or may not be possible and does not convey the empathy. It is sometimes
        difficult to believe what satanic cults can do to children. Option 2 diverts attention from the client to
        the mother. Option 3 shows more interest in the cult than the client.
        CN: Psychosocial integrity; CL: Synthesize

Question 122

122. A 15-year-old client diagnosed with posttraumatic stress disorder (PTSD) is admitted to the
     unit after slicing both arms with a razor blade. He says, “Maybe my mother will listen to me now. She
     tells me I’m just crazy when I say I’m screwed up because my stepdad had sex with me for years.” The
     nurse should do the following in which order of priority first to last?
123. Ask the client about the stepdad possibly abusing younger children in the family.
124. Ask the client to be specific about what he means by “screwed up.”
125. Ask the client to sign a No Harm Contract related to suicide and self-mutilation.
126. Ask the client to talk about appropriate ways to express anger toward his mother.

Answer 122

122.
3. Ask the client to sign a No Harm Contract related to suicide and self-mutilation.
1. Ask the client about the step-dad possibly abusing younger children in the family.
2. Ask the client to be specific about what he means by “screwed up.”
4. Ask the client to talk about appropriate ways to express anger toward his mother.
The nurse should first assure the client’s safety after the client’s self-mutilation. Another safety
issue is whether the stepdad possibly may be abusing younger children; if so, a police report may
need to be filed. Then, it is important to know what the client means exactly by “screwed up” to
identify other emotions and behaviors that need attention. It is very common for survivors of
childhood sexual abuse to have intense anger at those who did not stop or prevent the abuse, and once
the other steps have been taken, the nurse can begin to help the client manage his anger.
CN: Reduction of risk potential; CL: Synthesize

Question 123

123. A client diagnosed with posttraumatic stress disorder is readmitted for suicidal thoughts and
     continued trouble sleeping. She states that when she closes her eyes, she has vivid memories about
     being awakened at night. “My dad would be on top of me trying to have sex with me. I couldn’t
     breathe.” Which of the following suggestions would be appropriate for the nurse to make for the
     insomnia? Select all that apply.
124. Trying relaxation techniques to help decrease her anxiety before bedtime.
125. Taking the quetiapine (Seroquel) 25 mg as needed as prescribed by the primary health care provider.
126. Staying in the dayroom and trying to sleep in the recliner chair near staff.
127. Listening to calming music as she tries to fall asleep.
128. Processing the content of her flashbacks no less than an hour before bedtime.
129. Leaving her door slightly open to decrease noise during the nightly checks.

Answer 123

123. 1, 2, 4, 6. Relaxation techniques and listening to calming music decrease anxiety and
     promote sleep. Seroquel is often effective in decreasing nightmare and flashbacks and has a
     beneficial side effect of drowsiness. Leaving her door slightly open will decrease the noise of making
     15-minute checks at night. Staying in the dayroom in a recliner with all the noise and lights is not
     likely to help. Processing memories an hour or two before bedtime doesn’t allow enough time to calm
     down before sleep.CN: Psychosocial integrity; CL: Synthesize

Question 124

124. A client with posttraumatic stress disorder needs to find new housing and wants to wait for
     a month before setting another appointment to see the nurse. The nurse interprets this action as which
     of the following?
125. A method of avoidance.
126. A detriment to progress.
127. The end of treatment.
128. A necessary break in treatment.

Answer 124

124. 4. The nurse judges the client’s request for an interruption in treatment as a necessary break
        in treatment. A “time-out” is common and necessary to enable the client to focus on pressing problems
        and solutions. It is not necessarily a method of avoidance, a detriment to progress, or the end of
        treatment. A problem like housing can be very stressful and require all of the client’s energy and
        attention, with none left for the emotional stress of treatment.
        CN: Management of care; CL: Analyze

Question 125

necessary break in treatment.
125. The nurse should warn a client who is taking a benzodiazepine about using which of the
following medications in combination with his current medication?
1. Antacids.
2. Acetaminophen (Tylenol).
3. Vitamins.
4. Aspirin.

Answer 125

125. 1. Combining a benzodiazepine with an antacid impairs the absorption rate of the
        benzodiazepine. Acetaminophen, vitamins, and aspirin are safe to take with a benzodiazepine because
        no major drug interactions occur.
        CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 126

126. Which of the following client statements indicates the need for additional teaching about
     benzodiazepines?
127. “I can’t drink alcohol while taking diazepam (Valium).”
128. “I can stop taking the drug anytime I want.”
129. “Valium can make me drowsy, so I shouldn’t drive for a while.”
130. “Valium will help my tight muscles feel better.”

Answer 126

126. 2. Valium, like any benzodiazepine, cannot be stopped abruptly. The client must be slowly
        tapered off of the medication to decrease withdrawal symptoms, which would be similar to
        withdrawal from alcohol. Alcohol in combination with a benzodiazepine produces an increased
        central nervous system depressant effect and therefore should be avoided. Valium can cause
        drowsiness, and the client should be warned about driving until tolerance develops. Valium has
        muscle relaxant properties and will help tight, tense muscles feel better.
        CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 127

127. A client is diagnosed with agoraphobia without panic disorder. Which type of therapy is
most effective for this illness?
1. Insight therapy.
2. Group therapy.
3. Behavior therapy.
4. Psychoanalysis.

Answer 127

127. 3. The nurse should suggest behavior therapy, which is most successful for clients with
        phobias. Systematic desensitization, flooding, exposure, and self-exposure treatments are most
        therapeutic for clients with phobias. Self-exposure treatment is being increasingly used to avoid
        frequent therapy sessions. Insight therapy, exploration of the dynamics of the client’s personality, is
        not helpful because the process of anxiety underlies the disorder. Group therapy or psychoanalysis,
        which deals with repressed, intrapsychic conflicts, is not helpful for the client with phobias because
        it does not help to manage the underlying anxiety or disorder.
        CN: Psychosocial integrity; CL: Apply

Question 128

128. The client diagnosed with a fear of eating in public places or in front of other people has
     finished eating lunch in the dining area in the nurse’s presence. Which of the following statements by
     the nurse should reinforce the client’s positive action?
129. “It wasn’t so hard, now was it?”
130. “At supper, I hope to see you eat with a group of people.”
131. “You must have been hungry today.”
132. “It is progress for you to eat in the dining room with me.”

Answer 128

128. 4. Saying, “It’s a sign of progress to eat in the dining area with me,” conveys positive
        reinforcement and gives the client hope and confidence, thus reinforcing the adaptive behavior.
        Stating, “It wasn’t so hard, now was it,” decreases the client’s self-worth and minimizes his
        accomplishment. Stating, “At supper, I hope to see you eat with a group of people,” will overwhelm
        the client and increase anxiety. Stating, “You must have been hungry today,” ignores the client’s
        positive behavior and shows the nurse’s lack of understanding of the dynamics of the disorder.
        CN: Psychosocial integrity; CL: Synthesize

Question 129

129. The client diagnosed with agoraphobia refuses to walk down the hall to the group room.
     Which of the following responses by the nurse is appropriate?
130. “I know you can do it.”
131. “Try holding onto the wall as you walk.”
132. “You can miss group this one time.”
133. “I’ll walk with you.”

Answer 129

129. 4. The nurse should walk with the client to activate adaptive coping for the client
        experiencing high anxiety and decreased motivation and energy. Stating, “I know you can do it,” “Try
        holding on to the wall,” or “You can miss group this one time,” maintains the client’s avoidance, thus
        reinforcing the client’s behavior, and does not help the client begin to cope with the problem.
        CN: Psychosocial integrity; CL: Synthesize

Question 130

130. A client diagnosed with obsessive-compulsive disorder has been taking sertraline (Zoloft)
     but would like to have more energy every day. At his monthly checkup, he reports that his massage
     therapist recommended he take St. John’s wort to help his depression. The nurse should tell the client:
131. “St. John’s wort is a harmless herb that might be helpful in this instance.”
132. “Combining St. John’s wort with the Zoloft can cause a serious reaction called serotonin syndrome.”
133. “If you take St. John’s, we’ll have to decrease the dose of your Zoloft.”
134. “St. John’s wort isn’t very effective for depression, but we can increase your Zoloft dose.”

Answer 130

130. 2. The effectiveness of St. John’s wort with depression is unconfirmed. The critical issue is
        that the combination of St. John’s wort and Zoloft (a SSRI antidepressant) can produce serotoninsyndrome, which can be fatal. The client should not take the St. John’s wort while taking Zoloft.
        CN: Pharmacological and parenteral therapies; CL: Apply

Question 131

131. A client diagnosed with obsessive-compulsive disorder arrives late for an appointment with
     the nurse at the outpatient clinic. During the interview, he fidgets restlessly, has trouble remembering
     what topic is being discussed, and says he thinks he is going crazy. Which of the following statements
     by the nurse best deals with the client’s feelings of “going crazy?”
132. “What do you mean when you say you think you’re going crazy?”
133. “Most people feel that way occasionally.”
134. “I don’t know you well enough to judge your mental state.”
135. “You sound perfectly sane to me.”

Answer 131

131. 1. When the client says he thinks he is “going crazy,” it is best for the nurse to ask him what
        “crazy” means to him. The nurse must have a clear idea of what the client means by his words and
        actions. Using an open-ended question facilitates client description to help the nurse assess his
        meaning. The other statements minimize and dismiss the client’s concern and do not give him the
        opportunity to openly discuss his feelings, possibly leading to increased anxiety.
        CN: Psychosocial integrity; CL: Synthesize

Question 132

132. A client with obsessive-compulsive disorder reveals that he was late for his appointment
     “because of my dumb habit. I have to take off my socks and put them back on 41 times! I can’t stop
     until I do it just right.” The nurse interprets the client’s behavior as most likely representing an effort
     to obtain which of the following?
133. Relief from anxiety.
134. Control of his thoughts.
135. Attention from others.
136. Safe expression of hostility.

Answer 132

132. 1. A client who is exhibiting compulsive behavior is attempting to control his anxiety. The
        compulsive behavior is performed to relieve discomfort and to bind or neutralize anxiety. The client
        must perform the ritual to avoid an extreme increase in tension or anxiety even though the client is
        aware that the actions are absurd. The repetitive behavior is not an attempt to control thoughts; the
        obsession or thinking component cannot be controlled. It is not an attention-seeking mechanism or an
        attempt to express hostility.
        CN: Psychosocial integrity; CL: Analyze

Question 133

133. A client with obsessive-compulsive disorder, who was admitted early yesterday morning,
     must make his bed 22 times before he can have breakfast. Because of his behavior, the client missed
     having breakfast yesterday with the other clients. Which of the following actions should the nurse
     institute to help the client be on time for breakfast?
134. Tell the client to make his bed one time only.
135. Wake the client an hour earlier to perform his ritual.
136. Insist that the client stop his activity when it’s time for breakfast.
137. Advise the client to have breakfast first before making his bed.

Answer 133

133. 2. The nurse should wake the client an hour earlier to perform his ritual so that he can be on
        time for breakfast with the other clients. The nurse provides the client with time needed to perform
        rituals because the client needs to keep his anxiety in check. The nurse should never take away a
        ritual, because panic will ensue. The nurse should work with the client later to slowly set limits on
        the frequency of the action.
        CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 134

134. The nurse notices that a client diagnosed with major depression and social phobia must get
     up and move to another area when someone sits next to her. Which of the following actions by the
     nurse is appropriate?
135. Ignore the client’s behavior.
136. Question the client about her avoidance of others.
137. Convey awareness of the client’s anxiety about being around others.
138. Tell the other clients to follow the client when she moves away.

Answer 134

134. 3. The nurse conveys empathy and awareness of the client’s need to reduce anxiety by
        showing acceptance and understanding to the client, thereby promoting trust. Ignoring the behavior,
        questioning the client about her avoidance of others, or telling other clients to follow her when she
        moves are not therapeutic or appropriate.
        CN: Psychosocial integrity; CL: Synthesize

Question 135

135. The nurse is developing a long-term care plan for an outpatient client diagnosed with
     dissociative identity disorder. Which of the following should be included in this plan? Select all that
     apply.
136. Learning how to manage feelings, especially anger and rage.
137. Joining several outpatient support groups that are process-oriented.
138. Identifying resources to call when there is a risk of suicide or self-mutilation.
139. Selecting a method for alter personalities to communicate with each other, such as journaling.
140. Trying different medicines to find one that eliminates the dissociative process.
     Helping each alter accept the goal of sharing and integrating all their memories.

Answer 135

135. 1, 3, 4, 6. Managing suicidal thought, urges to self-mutilate, and the intense anger are critical
     safety issues. Then the focus can switch to communication methods for each alter and the integration
     issues. Process groups can be overwhelming when too much is revealed or when child alters are
     unable to understand the group content. There are no known medicines to stop the process of
     dissociating.
     CN: Management of care; CL: Create

Question 136

bbed at gunpoint. She did not report the robbery and could not be found for 2 days. In a city 100
miles (161 km) away, a hotel manager called the police because the woman gave a false name and
address. After learning that the robbery was confirmed by the bank cameras, she was admitted to the hospital with a diagnosis of dissociative fugue. The nurse should include which of the following in
the client’s care plan? Select all that apply.
1. Develop trust and rapport to provide safety and support.
2. Rule out possible physical and neurological causes for the fugue.
3. Help the client discuss what she can remember about the trip to the bank.
4. Seclude the client from the other clients because of her lack of memory.
5. Question her repeatedly about the robbery and how she responded.
6. Encourage the client to talk about her feelings about what has been happening.

Answer 136

136. 1, 2, 3, 6. A client experiencing a dissociate fugue needs to feel safe and supported as well
     as evaluated medically and neurologically. Then it is appropriate to discuss what she can remember
     about the trip to the bank and her feelings about all that has happened to her since then. It is not
     appropriate to seclude her from others or to apply pressure to get details about the crime at this time.
     The police and the bank will ask these questions during their investigations.
     CN: Psychosocial integrity; CL: Create

Question 137

137. A client with a long history of experiencing dissociative identity disorder is admitted to the
     unit after the cuts on her legs were sutured in the Emergency Department. During the admission
     interview, the client tearfully states that she does not know what happened to her legs. Then a
     stronger, alter personality states that the client is useless, weak, and needs to be eliminated
     completely. The nurse should do which of the following first?
138. Explore the alter personalities’ attitudes toward the client more thoroughly.
139. Place the client in restraints when the alter personality emerges.
140. Contract with the alter personality to tell the nurse when he has the urge to harm the client and the
     body they both share.
141. Keep the client in a stress-free environment so that the stronger alter personality does not get a
     chance to emerge.

Answer 137

137. 3. The No Harm Contract with any destructive alters is essential along with the reminder that
        the alters share the same body. Later, the alter’s attitudes about the client can be explored in moredepth. When alter personalities emerge, their behaviors are not predictable. Restraints could not be
        placed on the client soon enough. There are no behaviors to justify restraints at this point. Creating a
        stress-free environment is not possible.
        CN: Safety and infection control; CL: Synthesize

Question 138

The Client with a Somatoform Disorder
138. At 10 AM , a client with an Axis I diagnosis of pain disorder demands that the nurse call the
primary health care provider for more pain medication because she’s still in pain after the 9 AM
analgesic. Which of the following should the nurse do next?
1. Call the primary health care provider as the client requests.
2. Suggest the client lie down while she is waiting for her next dose.
3. Tell the client that the primary health care provider will be in later to talk to her about it.
4. Inform the client that the nurse cannot give her additional medication at this time.

Answer 138

The Client with a Somatoform Disorder
138. 4. The nurse sets limits by informing the client in a matter-of-fact manner that the nurse
cannot give her additional pain medication at this time. Then the nurse invites the client to participate
in a card game to decrease rumination about pain by directing the client’s attention to an activity. By
telling the client the nurse will call the primary health care provider as requested, the nurse is
manipulated to do what the client demands. Suggesting that the client lie down because she has to
wait for the next dosage or telling the client that the primary health care provider will be in later
ignores the client and her needs and is not helpful in decreasing rumination about her pain.
CN: Psychosocial integrity; CL: Synthesize

Question 139

139. The unlicensed assistive personnel (UAP) tells the nurse that the client with a somatoform
     disorder is sick and is not coming to the dining room for lunch. The nurse should direct the UAP to do
     which of the following?
140. Take the client a lunch tray and let him eat in his room.
141. Tell the client he’ll need to wait until supper to eat if he misses lunch.
     Invite the client to lunch and accompany him to the dining room.
142. Inform the client that he has 10 minutes to get to the dining room for lunch.

Answer 139

139. 3. The nurse instructs the UAP to invite the client to lunch and accompany him to the dining
        room to decrease manipulation, secondary gain, dependency, and reinforcement of negative behavior
        while maintaining the client’s self-worth. Taking the client a lunch tray and allowing him to eat in his
        room reinforces negative behaviors and secondary gain. Telling the client he’ll need to wait until
        supper to eat if he misses lunch or informing the client that he has 10 minutes to get to the dining room
        challenges the client and may increase feelings of anger and the need for physical complaints.
        CN: Management of care; CL: Synthesize

Question 140

140. The client diagnosed with conversion disorder has a paralyzed arm. A staff member states,
     “I would just tell the client her arm is paralyzed because she had an affair and neglected her baby’s
     care to the point where the baby had to be hospitalized for dehydration.” Which of the following
     responses by the nurse is best?
141. “Ignore the client’s behaviors and treat her with respect.”
     “Pushing insight will increase the client’s anxiety and the need for physical symptoms.”
142. “Pushing awareness will be helpful and further the client’s recovery.”
143. “We’ll meet with the client and confront her with her behavior.”

Answer 140

140. 2. Pushing insight or awareness into conflicts or problems increases anxiety and the need for
        physical symptoms to handle or take care of the anxiety. Awareness or insight must be developed
        slowly as the client’s need for symptoms diminishes. Saying “Ignore the client’s behavior and treat her
        with respect” is not helpful to the staff member or the client. This statement fails to educate the staff
        member about the client’s disorder and simply dismisses the needs of both. It is not true that pushing
        awareness will be helpful and further the client’s recovery; this is the opposite of what is needed.
        Meeting with the client to confront her behavior is not therapeutic and will greatly increase the
        client’s anxiety and the need for the conversion symptoms.
        CN: Management of care; CL: Synthesize

Question 141

141. The primary health care provider refers a client diagnosed with somatization disorder to the
     outpatient clinic because of problems with nausea. The client’s past symptoms involved back pain,
     chest pain, and problems with urination. The client tells the nurse that the nausea began when his wife
     asked him for a divorce. Which of the following is most appropriate?
142. Asking the client to describe his problem with nausea.
143. Directing the client to describe his feelings about his impending divorce.
144. Allowing the client to talk about the primary health care providers he has seen and the
     medications he has taken.
145. Informing the client about a different medication for his nausea.

Answer 141

141. 2. The nurse helps the client to focus on his feelings about his impending divorce to decrease
        the client’s anxiety and decrease his focus on physical ailments. The client with a somatoform
        disorder typically has problems with identifying, describing, and dealing with feelings. Internalizing
        feelings leads to increased anxiety and the need for protective mechanisms. Asking the client to
        describe his problem with nausea, allowing the client to talk about the many primary health care
        providers he has seen and the medications he has taken, and informing the client about a different
        medication for nausea are counterproductive toward recovery because they reinforce the focus on the
        symptoms.
        CN: Psychosocial integrity; CL: Synthesize

Question 142

142. A client diagnosed with pain disorder is talking with the nurse about fishing when he
     suddenly reverts to talking about the pain in his arm. Which of the following should the nurse do next?
143. Allow the client to talk about his pain.
144. Ask the client if he needs more pain medication.
145. Get up and leave the client.
146. Redirect the interaction back to fishing.

Answer 142

142. 4. The nurse should redirect the interaction back to fishing or another focus whenever the
        client begins to ruminate about physical symptoms or impairment. Doing so helps the client talk about
        topics that are more therapeutic and beneficial to recovery. Allowing the client to talk about his painor asking if he needs additional pain medication is not therapeutic because it reinforces the client’s
        need for the symptom. Getting up and leaving the client is not appropriate unless the nurse has set
        limits previously by saying, “I will get up and leave if you continue to talk about your pain.”
        CN: Psychosocial integrity; CL: Synthesize

Question 143

143. Which of the following statements indicates to the nurse that the client is progressing toward
     recovery from a somatoform disorder?
144. “I understand my pain will feel worse when I’m worried about my divorce.”
145. “My stomach pain will go away once I get properly diagnosed.”
146. “My headache feels better when I time my medication dose.”
147. “I need to find a doctor who understands what my pain is like.”

Answer 143

143. 1. The client who states, “I understand my pain will feel worse when I’m worried about my
        divorce” recognizes the connection between his pain and the divorce and indicates developing insight
        into his problem. The nurse should then be able to assist the client with developing adaptive coping
        strategies. The other statements indicate a lack of insight into his disorder and lack of progress
        toward recovery. The client is still searching for the “right” diagnosis, medication, and doctor.
        CN: Psychosocial integrity; CL: Evaluate

Question 144

Managing Care Quality and Safety
144. A client is brought to the emergency department (ED) by a friend who states that the client
recently ran out of his lorazepam (Ativan) and has been having a grand mal seizure for the last 10
minutes. The nurse observes that the client is still seizing. The nurse should do the following in which
order of priority from first to last?
1. Monitor the client’s safety and place seizure pads on the cart rails.
2. Record the time, duration, and nature of the seizures.
3. Page the ED primary health care provider and prepare to give diazepam (Valium)
intravenously.
4. Ask the friend about the client’s medical history and current medications.

Answer 144

Managing Care Quality and Safety
144.
3. Page the ED primary health care provider and prepare to give diazepam (Valium)
intravenously.
1. Monitor the client’s safety and place seizure pads on the cart rails.
2. Record the time, duration and nature of the seizures.
4. Ask the friend about the client’s medical history and current medications.
The nurse should first obtain a prescription for and administer diazepam (Valium) to stop the
status epilepticus. The nurse should next prevent injury by using seizure pads. Recording the time,
duration, and nature of the seizures will be important for ongoing treatment. Finally, the nurse can
attempt to obtain information about medication use and abuse history from the friend until the client is
able to do so for himself.
CN: Safety and infection control; CL: Synthesize

Question 145

145. A 33-year-old client named Becky, who is diagnosed with dissociative identity disorder, is
     admitted to the unit after a suicide attempt. During a group therapy session the next morning, the topic
     of anger toward parents came up. Becky suddenly throws herself on the floor and starts screaming,
     “Mommy, Mommy, help Annie girl, help Annie girl.” The nurse should take the following actions in
     which order of priority from first to last?
146. Ask the other clients to leave the room and meet with another nurse.
147. Ask Becky to talk about what happened to her during the group therapy session.
148. Get close to Annie and protect her from injury until she calms down.
149. Ask Annie about what happened to her during the group.

Answer 145

145.
3. Get close to Annie and protect her from injury until she calms down.
1. Ask the other clients to leave the room and meet with another nurse.
4. Ask Annie about what happened to her during the group.
2. Ask Becky to talk about what happened to her during the group therapy session.The safety of the client is the top priority. Then the nurse can ask the other clients to leave and
meet with another nurse to discuss their feelings about what happened in the group session since this
event will likely be very disturbing to the other group members. When Annie, the alter personality, is
calmer, the nurse can discuss what triggered her emergence and what she experienced. Then when
Becky reemerges, it is appropriate to discuss what she remembers and her feeling about the event.
CN: Safety and infection control; CL: Synthesize

Question 146

146. The client is in the emergency department with her boyfriend. She is just recovering from a
     “bad trip” from lysergic acid diethylamide (LSD). She is still frightened and a little suspicious.
     Which of the following nursing actions is most appropriate?
147. Having a sitter stay with the client to decrease her fear.
148. Placing the client next to the nursing desk.
149. Leaving the client alone until the “trip” is over.
150. Having the boyfriend check on the client frequently.

Answer 146

146. 1. Having a qualified sitter stay with the client provides for reassurance and safety. Being
        next to the nursing desk will increase stimuli and confusion. Being alone will increase the client’s
        fears and anxiety. It is inappropriate to ask the boyfriend to provide client supervision for the nurse.
        CN: Safety and infection control; CL: Synthesize

Question 147

147. A client on a stretcher in the emergency department begins to thrash around, slap the sheets,
     and yell, “Get these bugs off of me.” She is disoriented and has a blood pressure of 189/75 and a
     pulse of 96. The friend who is with her says, “She was drinking a lot 3 days ago and asked me for
     money to get more vodka, but I didn’t have any.” The nurse should do the following in which order
     from first to last?
148. Obtain a prescription to place the client in restraints, if needed.
149. Implement constant observation.
150. Monitor vital signs every 15 minutes.
151. Administer haloperidol (Haldol) and lorazepam (Ativan) IM as prescribed.
152. Remind the client that she is in the hospital and the nurse is with her.
153. Chart the client’s response to the interventions.

Answer 147

147.
5. Remind the client that she is in the hospital and the nurse is with her.
2. Implement constant observation.
4. Administer haloperidol (Haldol) and lorazepam (Ativan) IM as prescribed
3. Monitor vital signs every 15 minutes.
1. Obtain a prescription to place the client in restraints, if needed.
6. Chart the client’s response to the interventions.
After orienting the client to time and place, the nurse should assure constant observation of the
client to prevent the client from getting hurt. The administration of the Haldol and Ativan are needed
to quickly decrease the symptoms of delirium tremens (DTs) and lower the vital signs. Monitoring
vital signs assesses the client’s stability and need for additional medications. The nurse can ask
another staff to contact the health care provider to request a prescription for restraints in case the
client becomes violent toward self or others. After the DT symptoms subside, the Haldol would be
stopped due to the decrease in the seizure threshold. Other detoxification protocols would then begin.
Last, chart the client’s response.
CN: Safety and infection control; CL: Synthesize

Question 148

148. The nurse is teaching unlicensed staff about caring for the client with alcohol dependency.
     Which of the following statements by the staff indicates the need for additional teaching?
149. “Alcohol dependency affects the entire family.”“The client is a weak individual and could stop if he desires.”
150. “Alcohol is a problem when it interferes with the client’s daily life.”
151. “The client who can’t stop drinking even though he wants to is alcohol dependent.”

Answer 148

148. 2. The statement, “The client is a weak individual and could stop if he desires,” is false and
        indicates a lack of understanding regarding alcohol dependency. Criteria for substance dependency
        includes the inability to stop using even when wanting to do so. The client cannot stop or control the
        amount used when dependent on a substance. Alcohol dependency affects individuals from every
        culture and socioeconomic background and has nothing to do with being a “weak” individual. The
        devastating effects of alcohol dependency are felt by every member of the family and not just theindividual with the alcohol problem. Family members need education about the physical, physiologic,
        and psychological effects of alcohol and referrals to self-help groups for support. They have felt and
        lived with the devastating effects of the disease. A simple and commonly held view of alcoholism is
        that alcohol is a problem when it interferes with life or disrupts family, work, or social relationships.
        CN: Management of care; CL: Evaluate

Question 149

149. The nurse is serving on the hospital ethics committee that is considering the ethics of a
     proposal for the nursing staff to search the room of a client diagnosed with substance abuse while he
     is off the unit and without his knowledge. Which of the following should be considered concerning the
     relationship of ethical and legal standards of behavior?
     Ethical standards are generally higher than those required by law.
150. Ethical standards are equal to those required by law.
151. Ethical standards bear no relationship to legal standards for behavior.
152. Ethical standards are irrelevant when the health of a client is at risk.

Answer 149

149. 1. Some behavior that is legally allowed might not be considered ethically appropriate.
        Legal and ethical standards are often linked, such as in the commandment “Thou shalt not kill.”
        Ethical standards are never irrelevant, though a client’s safety or the safety of others may pose an
        ethical dilemma for health care personnel. Searching a client’s room when they are not there is a
        violation of their privacy. Room searches can be done with a primary health care provider’s
        prescription and generally are done with the client present.
        CN: Management of care; CL: Apply

Question 150

150. Two nurses are working on a pediatric unit. Over the past week, Nurse 1 has noticed that
     Nurse 2 is complaining more about her chronic back pain. Nurse 2 also says she is tired and drowsy
     at work. She is having trouble remembering which treatments she has done. Around the same time, a
     client of Nurse 2 reports that his pain medication is not helping at all. Nurse 1 asks Nurse 2 to have
     lunch with her to address her concerns about her. In which order of priority from first to last should
     Nurse 1 address the following issues with Nurse 2?
151. The type, dose, and frequency of use of the pain medication by Nurse 2.
152. The importance of the two of them going to their supervisor about Nurse 2’s recent problems.
153. Nurse 1’s genuine concern about Nurse 2, her pain, and behaviors.
154. Nurse 1’s suspicion that Nurse 2 may be using a client’s pain medication for herself.

Answer 150

150.
3. Nurse 1’s genuine concern about Nurse 2, her pain, and behaviors.
1. The type, dose, and frequency of use of the pain medication by Nurse 2.
4. Nurse 1’s suspicion that Nurse 2 may be using a client’s pain medication for herself.
2. The importance of the two of them going to their supervisor about Nurse 2’s recent problems.
Unless Nurse 2 believes that Nurse 1 cares about her and her needs, she is likely to deny having
any problem. Knowing details about Nurse 2’s pain medications, helps Nurse 1 assess the severity of
Nurse 2’s medication abuse. Then it is appropriate to address the possibility of Nurse 2 using a
client’s pain medication. Going to their supervisor is the next step in helping Nurse 2 get treatment
assistance.
CN: Management of care; CL: Analyze

Question 151

151. A client with a history of cocaine abuse is receiving intravenous therapy and exits the
     hospital “to visit a friend.” The client returns to the nursing unit 1 hour later, agitated, aggressive,
     combative, and reporting “chest pain.” Place the nurse’s actions in priority order.
152. Contact the security department.
153. Obtain an EKG.3. Initiate a referral to obtain drug rehabilitation counseling.
154. Obtain a prescription for a urine sample.

Answer 151

151.
1. Contact the security department.
2. Obtain an EKG.
4. Obtain a prescription for a urine sample.
3. Initiate a referral to obtain drug rehabilitation counseling.The nurse should first provide for safety of the client and the staff by requesting assistance from
the security department. Next, the nurse should obtain an EKG because the client reports having chest
pain. The nurse should then obtain a prescription for a urine sample to identify if the client has been
using illegal drugs. When the client is stabilized, the nurse can develop a care plan that includes
treatment goals to support the respiratory and cardiovascular functions and enhance clearance of the
agent, and initiate a referral for treatment where access to the drug is eliminated and drug
rehabilitation is provided as part of therapeutic management of clients with substance abuse and/or a
drug overdose.
CN: Reduction of risk potential; CL: Analyze