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NURS 316 exam 2 Questions With
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What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal? correct answer: Risk for injury R/T central nervous system stimulation A nurse evaluates a client's patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance use disorder? correct answer: Clients who are regularly using alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. On the first day of a client's alcohol detoxification, which nursing intervention should take priority? correct answer: Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. Which client statement indicates a knowledge deficit related to substance use? correct answer: "Marijuana is like smoking cigarettes. Everyone does it. It's essentially harmless." A lonely, depressed divorcée has been self-medicating with cocaine for the past year. Which term should a nurse use to best describe this individual's situation? correct answer: The individual is experiencing psychological addiction.
Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during alcohol withdrawal? correct answer: Substitution therapy A client diagnosed with chronic alcohol use disorder is being discharged from an inpatient treatment facility after detoxification. Which client outcome related to Alcoholics Anonymous (AA) would be most appropriate for a nurse to discuss with the client during discharge teaching? correct answer: After discharge, the client will immediately attend 90 AA meetings in 90 days. A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 24 hours. Which client symptom should the nurse immediately report to the ED physician? correct answer: Blood pressure of 180/100 mm Hg Which client statement demonstrates positive progress toward recovery from a substance use disorder? correct answer: Taking those pills got out of control. It cost me my job, marriage, and children." A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse's rationale for this intervention? correct answer: To assess for fine tremors Upon admission for symptoms of alcohol withdrawal, a client states, "I haven't eaten in 3 days." Assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97F (36C) with dry skin, dry mucous membranes, and poor skin turgor. What should be
accomplish? correct answer: the client will correlate life problems with alcohol use. A nurse is reviewing STAT laboratory data of a client presenting in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur? correct answer: 100 mg/dL A client has a history of daily bourbon drinking for the past 6 months. He is brought to an emergency department by family, who report that his last drink was 1 hour ago. It is now 12 midnight. When should a nurse expect this client to exhibit withdrawal symptoms? correct answer: Between 3 a.m. and 11 a.m. A client diagnosed with depression and substance use disorder has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions? correct answer: Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. A client with a history of insomnia has been taking chlordiazepoxide (Librium), 15 mg, at night for the past year. The client currently reports that this dose is no longer helping him fall asleep. Which nursing diagnosis appropriately documents this problem? correct answer: Disturbed sleep pattern R/T Librium tolerance AEB difficulty falling asleep
A client is admitted for alcohol detoxification. During detoxification, which symptoms should the nurse expect to assess? correct answer: Gross tremors, delirium, hyperactivity, and hypertension A recovering alcoholic relapses and drinks a glass of wine. The client presents in the emergency department (ED) experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. What may these symptoms indicate to the ED nurse? correct answer: A reaction to disulfiram (Antabuse) A client is questioning the nurse about a newly prescribed medication, acamprosate calcium (Campral). Which is the most appropriate reply by the nurse? correct answer: "This medication will help you maintain your abstinence." A nurse is caring for a client who has been prescribed disulfiram (Antabuse) as a deterrent to alcohol relapse. Which information should the nurse include when teaching the client about this medication? correct answer: "Reactions to combining Antabuse with alcohol can occur for as long as 2 weeks after stopping the drug." Which is the priority nursing intervention for a client admitted for acute alcohol intoxication? correct answer: Assess aggressive behaviors in order to intervene to prevent injury to self or others. A client diagnosed with alcohol use disorder joins a community 12-step program and states, "My life is unmanageable." How
C. "In this condition, blood accumulates in the abdominal cavity." A high school senior is diagnosed with anorexia nervosa and is hospitalized for severe malnutrition. The treatment team is planning to use behavior modification. What rationale should a nurse identify as the reasoning behind this therapy choice? correct answer: This therapy will provide the client with control over behavioral choices. Family dynamics are thought to be a major influence in the development of anorexia nervosa. Which information related to a client's home environment should a nurse associate with the development of this disorder? correct answer: The home environment is overprotective and demands perfection. A client's altered body image is evidenced by claims of "feeling fat," even though the client is emaciated. Which is the appropriate outcome criterion for this client's problem? correct answer: The client will perceive an ideal body weight and shape as normal. A nurse observes dental deterioration when assessing a client diagnosed with bulimia nervosa. What explains this assessment finding? correct answer: The emesis produced during purging is acidic and corrodes the tooth enamel. Why are behavior modification programs the treatment of choice for clients diagnosed with eating disorders? correct answer: these programs allow clients to maintain control.
A potential Olympic figure skater collapses during practice and is hospitalized for severe malnutrition. Anorexia nervosa is diagnosed. Which client statement best reflects a theory about the underlying etiology of this disorder? correct answer: "I am angry at my mother. I can get her approval only when I win competitions." The family of a client diagnosed with anorexia nervosa becomes defensive when the treatment team calls for a family meeting. Which is the appropriate nursing reply? correct answer: "Family intervention and support are important in your child's recovery." A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change? correct answer: The client demonstrates healthy coping mechanisms that decrease anxiety. A morbidly obese client is prescribed an anorexiant medication. The nurse should prepare to teach the client about which medication? correct answer: Lorcaserin (Belviq) A nursing instructor is teaching students about the differences between the symptoms of anorexia nervosa and the symptoms of bulimia nervosa. Which student statement indicates that learning has occurred? correct answer: "Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not." A client diagnosed with bulimia nervosa is to receive fluoxetine (Prozac) by oral solution. The medication is supplied in a 100-
intervention? correct answer: To emphasize that the client is capable of consuming food without purging A client diagnosed with anorexia nervosa stopped eating 5 months ago and lost 25% of total body weight. Which subjective client response would the nurse assess to support this medical diagnosis? correct answer: "I don't know why people are worried. I need to lose this weight." A nursing diagnosis of ineffective coping R/T feelings of loneliness AEB bingeing then purging when alone, is assigned to a client diagnosed with bulimia nervosa. Which is an appropriate outcome related to this nursing diagnosis? correct answer: The client will identify two alternative methods of dealing with isolation by day 3. A nurse responsible for conducting group therapy on an eating disorder unit schedules the sessions immediately after meals. Which is the best rationale for scheduling group therapy at this time? correct answer: To promote the processing of anxiety associated with eating Which nursing intervention is appropriate when caring for clients diagnosed with either anorexia nervosa or bulimia nervosa? correct answer: Remain with the client for at least 1 hour after the meal. A nurse should identify topiramate (Topamax) as the drug of choice for which of the following conditions? Select all that apply. correct answer: A. Binge eating with obesity B. Bingeing and purging with a diagnosis of bulimia nervosa
Which developmental characteristic should a nurse identify as typical of a client diagnosed with severe intellectual disability? correct answer: The client communicates wants and needs by "acting out" behaviors. Which nursing intervention related to self-care would be most appropriate for a teenager diagnosed with moderate intellectual disability? correct answer: Providing simple directions and praising client's independent self-care efforts A child has been diagnosed with autism spectrum disorder. The distraught mother cries out, "I'm such a terrible mother. What did I do to cause this?" Which nursing reply is most appropriate? correct answer: "Poor parenting doesn't cause autism. Research has shown that abnormalities in brain structure and/or function are to blame. This is beyond your control." In planning care for a child diagnosed with autistic spectrum disorder, which would be a realistic client outcome? correct answer: he client will establish trust with at least one caregiver by day 5. After an adolescent diagnosed with attention deficit- hyperactivity disorder (ADHD) begins methylphenidate (Ritalin) therapy, a nurse notes that the adolescent loses 10 pounds in a 2-month period. What is the best explanation for this weight loss? correct answer: The pharmacological action of Ritalin causes a decrease in appetite.
more secure on the unit, which intervention should a nurse correct answer: Provide consistent caregivers. A preschool child diagnosed with autism spectrum disorder has been engaging in constant head-banging behavior. Which nursing intervention is appropriate? correct answer: Hold client's head steady and apply a helmet. When planning care for a client, which medication classification should a nurse recognize as effective in the treatment of Tourette's disorder? correct answer: Antipsychotic medications Which behavioral approach should a nurse utilize when caring for children diagnosed with disruptive behavior disorders? correct answer: Reinforcing positive actions to encourage repetition of desired behaviors A child diagnosed with autism spectrum disorder has the nursing diagnosis of disturbed personal identity. Which outcome would best address this client's diagnosis? correct answer: The client will name own body parts as separate from others by day 5. A nursing instructor presents a case study in which a 3-year-old child is in constant motion and is unable to sit still during story time. The instructor asks a student to evaluate this child's behavior. Which student response indicates an appropriate evaluation of the situation? correct answer: This child's behavior must be evaluated according to developmental norms." A client has an IQ of 47. Which nursing diagnosis best addresses a client problem associated with this degree of intellectual
disability? correct answer: Altered social interaction R/T nonadherence to social convention A physician orders methylphenidate (Ritalin) for a child diagnosed with attention deficit-hyperactivity disorder (ADHD). Which information about this medication should the nurse provide to the parents? correct answer: Administer Ritalin to the child after breakfast. Which should be the priority nursing intervention when caring for a child diagnosed with conduct disorder? correct answer: Recognize escalating aggressive behaviors and intervene before violence occurs. A mother questions the decreased effectiveness of methylphenidate (Ritalin), prescribed for her child's attention deficit-hyperactivity disorder (ADHD). Which nursing reply best addresses the mother's concern? correct answer: "Your child has probably developed a tolerance to Ritalin and may need a higher dosage." A nurse has taken report for the evening shift on an adolescent inpatient unit. Which client should the nurse address first? correct answer: A client diagnosed with conduct disorder who is verbally abusing a peer in the milieu A 6-year-old client is prescribed methylphenidate (Ritalin) for a diagnosis of attention deficit-hyperactivity disorder (ADHD). When teaching the parents about this medication, which nursing statement explains how Ritalin works? correct answer: How
Which of the following interventions should a nurse anticipate implementing when planning care for children diagnosed with attention deficit-hyperactivity disorder (ADHD)? Select all that apply. correct answer: A. Behavior modification D. Group therapy E. Family therapy The nurse should recognize which of the following findings contribute to a client's development of attention deficit- hyperactivity disorder (ADHD)? Select all that apply. correct answer: B. The client was born 7 weeks premature. D. The client has a sibling diagnosed with ADHD. A client has recently been placed in a long-term-care facility because of marked confusion and inability to perform most activities of daily living. Which nursing intervention is most appropriate to maintain the client's self-esteem? correct answer: Allow client to choose between two different outfits when dressing for the day. A son who recently brought his extremely confused parent to a nursing home for admission reports feelings of guilt. Which is the appropriate nursing reply? correct answer: "People often have mixed emotions about decisions like this. Support groups are held here on Mondays for children of residents in similar situations." A family asks why their father is attending activity groups at the long-term care facility. The son states, "My father worked hard all of his life. He just needs some rest at this point." Which is the
appropriate nursing reply? correct answer: "The groups benefit your father by providing social interaction, sensory stimulation, and reality orientation." A nursing instructor is teaching about reminiscence therapy. What student statement indicates that learning has occurred? correct answer: "Reminiscence therapy encourages members to share both positive and negative significant life memories to promote resolution." A couple resides in a long-term care facility. The husband is admitted to the psychiatric unit after physically abusing his wife. He states, "My wife is having an affair with a young man, and I want it investigated." Which is the appropriate nursing reply? correct answer: "I understand that you are upset. Let's talk about it." Which psychiatric disorder would a nurse expect to see diagnosed in a client's later life? correct answer: Major depressive disorder An elderly client who lives with a caregiver is admitted to an emergency department for a fractured arm. The client is soaked in urine and has dried fecal matter on lower extremities. The client is 6 feet tall and weighs 120 pounds. Which condition should the nurse suspect? correct answer: Abuse, neglect, or both An elderly, emaciated client is brought to an emergency department by the client's caregiver. The client has bruises and abrasions on shoulders and back in multiple stages of healing.
A client diagnosed with glaucoma is being discharged to an assisted living facility. In what way should the discharge nurse modify teaching to most effectively present information to this client? correct answer: Reinforce critical content by providing large-print handouts. A kindergarten student is frequently violent toward other children. A school nurse notices bruises and burns on the child's face and arms. What other symptom should indicate to the nurse that the child might have been physically abused? correct answer: The child shrinks at the approach of adults. A woman describes a history of physical and emotional abuse in intimate relationships. Which additional factor should a nurse suspect? correct answer: The woman might be a victim of incest. Which statement made by an emergency department nurse indicates accurate knowledge of domestic violence? correct answer: "Power and control are central to the dynamic of domestic violence." A client is brought to an emergency department after being violently raped. Which nursing action is appropriate? correct answer: Remain nonjudgmental and actively listen to the client's description of the event. In the emergency department, a raped client appears calm and exhibits a blunt affect. The client answers a nurse's questions in a monotone using single words. How should the nurse interpret
this client's responses? correct answer: The client may be demonstrating a controlled response pattern. A client who is in a severely abusive relationship is admitted to a psychiatric inpatient unit. The client fears for her life. A staff nurse asks, "Why doesn't she just leave him?" Which is the nursing supervisor's most appropriate reply? correct answer: These clients are paralyzed into inaction by a combination of physical threats and a sense of powerlessness." A woman comes to an emergency department with a broken nose and multiple bruises after being beaten by her husband. She states, "The beatings have been getting worse, and I'm afraid that next time he might kill me." Which is the appropriate nursing reply? correct answer: "Let's talk about your options so that you don't have to go home." A college student was sexually assaulted when out on a date. After several weeks of crisis intervention therapy, which client statement should indicate to a nurse that the student is handling this situation in a healthy manner? correct answer: "I know that it was not my fault." A nursing student asks an emergency department nurse, "Why does a rapist use a weapon during the act of rape?" Which nursing reply is most accurate? correct answer: A weapon is used to terrorize and subdue the victim." When questioned about bruises, a woman states, "It was an accident. My husband just had a bad day at work. He's being so gentle now and even brought me flowers. He's going to get a
