subs abuse

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Topic: Substance Abuse, Eating disorders, Impulse control disorders. Topic: Substance Abuse, Eating disorders, Impulse control disorders. http://www.pinoybsn.tk 1. An unemployed woman, age 24, seeks help because she feels depressed and abandoned and doesn't know what to do with her life. She says she has quit her last five jobs because her coworkers didn't like her and didn't train her adequately. Last week, her boyfriend broke up with her after she drove his car into a tree after an argument. The client's initial diagnosis is borderline personality disorder. Which nursing observations support this diagnosis? A. Flat affect, social withdrawal, and unusual dress B. Suspiciousness, hypervigilance, and emotional coldness C. Lack of self-esteem, strong dependency needs, and impulsive C. Lack of self-esteem, strong dependency needs, and impulsive behavior behavior D. Insensitivity to others, sexual acting out, and violence Rationale: Borderline personality disorder is characterized by lack of self-esteem, strong dependency needs, and impulsive behavior. Instability in interpersonal relationships, mood, and poor self-image also is common. Typically, the client can't tolerate being alone and expresses feelings of emptiness or boredom. Flat affect, social withdrawal, and unusual dress are characteristic of schizoid personality disorder. Suspiciousness, hypervigilance, and emotional coldness are seen in paranoid personality disorders. In antisocial personality disorder, clients are usually insensitive to others and act out sexually; they may also be violent 2.In a toddler, which of the following injuries is most likely the result of child abuse? A. A hematoma on the occipital region of the head B. A 1-inch forehead laceration C. Several small, dime-sized circular burns on the child's back C. Several small, dime-sized circular burns on the child's back D. A small isolated bruise on the right lower extremity 89 Item Psychiatric Nursing Exam II : Substance Abuse, Eating disorders and Impulse control disorders Correct Answers and Rationale

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Page 1: Subs Abuse

Topic: Substance Abuse, Eating disorders, Impulse control disorders.Topic: Substance Abuse, Eating disorders, Impulse control disorders. http://www.pinoybsn.tk

1. An unemployed woman, age 24, seeks help because she feels depressed andabandoned and doesn't know what to do with her life. She says she has quit herlast five jobs because her coworkers didn't like her and didn't train heradequately. Last week, her boyfriend broke up with her after she drove his carinto a tree after an argument. The client's initial diagnosis is borderlinepersonality disorder. Which nursing observations support this diagnosis?

A. Flat affect, social withdrawal, and unusual dressB. Suspiciousness, hypervigilance, and emotional coldnessC. Lack of self-esteem, strong dependency needs, and impulsiveC. Lack of self-esteem, strong dependency needs, and impulsivebehaviorbehaviorD. Insensitivity to others, sexual acting out, and violence

Rationale: Borderline personality disorder is characterized by lack of self-esteem,strong dependency needs, and impulsive behavior. Instability in interpersonalrelationships, mood, and poor self-image also is common. Typically, the clientcan't tolerate being alone and expresses feelings of emptiness or boredom. Flataffect, social withdrawal, and unusual dress are characteristic of schizoidpersonality disorder. Suspiciousness, hypervigilance, and emotional coldnessare seen in paranoid personality disorders. In antisocial personality disorder,clients are usually insensitive to others and act out sexually; they may also beviolent

2.In a toddler, which of the following injuries is most likely the result of childabuse?

A. A hematoma on the occipital region of the headB. A 1-inch forehead lacerationC. Several small, dime-sized circular burns on the child's backC. Several small, dime-sized circular burns on the child's backD. A small isolated bruise on the right lower extremity

89 Item Psychiatric Nursing Exam II : Substance Abuse, Eatingdisorders and Impulse control disorders Correct Answers andRationale

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Rationale: Small circular burns on a child's back are no accident and may befrom cigarettes. Toddlers are injury prone because of their developmental stage,and falls are frequent because of their unsteady gait; head injuries aren'tuncommon. A small area of ecchymosis isn't suspicious in this age-group.

3. A client is admitted to the emergency department after being foundunconscious. Her blood pressure is 82/50 mm Hg. She is 5′ 4" (1.6 m) tall,weighs 79 lb (35.8 kg), and appears dehydrated and emaciated. After regainingconsciousness, she reports that she has had trouble eating lately and can'tremember what she ate in the last 24 hours. She also states that she has hadamenorrhea for the past year. She is convinced she is fat and refuses food. Thenurse suspects that she has:

A. bulimia nervosa.B. anorexia nervosa.B. anorexia nervosa.C. depression.D. schizophrenia.

Rationale: Anorexia nervosa is an eating disorder characterized by self-imposedstarvation with subsequent emaciation, nutritional deficiencies, and atrophic andmetabolic changes. Typically, the client is hypotensive and dehydrated.Depending on the severity of the disorder, anorexic clients are at risk forcirculatory collapse (indicated by hypotension), dehydration, and death. Bulimianervosa is an eating disorder characterized by binge eating followed by self-induced vomiting. Although depression may be accompanied by weight loss, itisn't characterized by a body image disturbance or the intense fear of obesityseen in anorexia nervosa. Schizophrenia may cause bizarre eating patterns, butit rarely causes the full syndrome of anorexia nervosa.

4. A 15-year-old girl with anorexia has been admitted to a mental health unit. Sherefuses to eat. Which of the following statements is the best response from thenurse?

A. "You don't have to eat. It's your choice."B. "I hope you'll eat your food by mouth. Tube feedings and I.V. linesB. "I hope you'll eat your food by mouth. Tube feedings and I.V. linescan be uncomfortable."can be uncomfortable."C. "Why do you think you're fat? You're underweight. Here — look in the mirror."D. "You really look terrible at this weight. I hope you'll eat."

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Rationale: Clients with anorexia can refuse food to the point of cardiac damage.Tube feedings and I.V. infusions are ordered to prevent such damage. The nurseis informing her of her treatment options. Option A doesn't tell the client about theconsequences of choosing not to eat. Telling clients that they are too thin won'tchange their self-image.

5. A client with a history of substance abuse has been attending AlcoholicsAnonymous meetings regularly in the psychiatric unit. One afternoon, the clienttells the nurse, "I'm not going to those meetings anymore. I'm not like the rest ofthose people. I'm not a drunk. "What is the most appropriate response?

A. "If you aren't an alcoholic, why do you keep drinking and ending up in thehospital?"B. "It's your decision. If you don't want to go, you don't have to."C. "You seem upset about the meetings."C. "You seem upset about the meetings."D. "You have to go to the meetings. It's part of your treatment plan."

Rationale: The substance abuser uses the substance to cope with feelings andmay deny the abuse. Asking if the client is upset about the meetings encouragesthe client to identify and deal with feelings instead of covering them up. Arguingwith the client about the substance abuse (option A) or insisting that the clientattend the meetings (option D) wouldn't help the client identify resistance totreatment. Option B isn't therapeutic behavior because it plays down theimportance of attending meetings.

6. A client is admitted to the inpatient adolescent unit after being arrested forattempting to sell cocaine to an undercover police officer. The nurse plans towrite a behavioral contract. To best promote compliance, the contract should bewritten:

A. abstractly.B. by the client alone.C. jointly by the client and nurse.C. jointly by the client and nurse.D. jointly by the physician and nurse.

Rationale: A contract written jointly by the client and nurse most successfullypromotes cooperation and consistent behavior. The most effective contract —and the type least likely to allow for manipulation and misinterpretation — statesthe behavioral terms as concretely as possible. A contract written solely by theclient may not be agreeable to staff members; one written by the physician and

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nurse may not be agreeable to the client.

7. During which phase of alcoholism is loss of control and physiologicdependence evident?

A. Prealcoholic phaseB. Early alcoholic phase

C. Crucial phaseC. Crucial phaseD. Chronic phase

Rationale: The crucial phase is marked by physical dependence. Theprealcoholic phase is characterized by drinking to medicate feelings and forrelief from stress. The early phase is characterized by sneaking drinks,blackouts, rapidly gulping drinks, and preoccupation with alcohol. The chronicphase is characterized by emotional and physical deterioration.

8. Which of the following is important when restraining a violent client?

A. Have three staff members present, one for each side of the body and one forthe head.B. Always tie restraints to side rails.

C. Have an organized, efficient team approach after the decision isC. Have an organized, efficient team approach after the decision ismade to restrain the client.made to restrain the client.D. Secure restraints to the gurney with knots to prevent escape.

Rationale: Emergency department personnel should use an organized, teamapproach when restraining violent clients so that no one is injured in the process.The leader, located at the client's head, should take charge; four staff membersare required to hold and restrain the limbs. For safety reasons, restraints shouldbe fastened to the bed frame instead of the side rails. For quick release, loopsshould be used instead of knots

9. A client who's actively hallucinating is brought to the hospital by friends. Theysay that the client used either lysergic acid diethylamide (LSD) or angel dust(phencyclidine [PCP]) at a concert. Which of the following common assessmentfindings indicates that the client may have ingested PCP?

A. Dilated pupilsB. NystagmusB. NystagmusC. Paranoia

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D. Altered mood

Rationale: Phencyclidine is an anesthetic with severe psychological effects. Itblocks the reuptake of dopamine and directly affects the midbrain and thalamus.Nystagmus and ataxia are common physical findings of PCP use. Dilated pupilsare evidence of LSD ingestion. Paranoia and altered mood occur with both PCPand LSD ingestion.

10. A severely dehydrated teenager admitted to the hospital with hypotensionand tachycardia undergoes evaluation for electrolyte disturbances. Her historyincludes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the last month. Sheis 5′ 7" (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention takeshighest priority?

A. Initiating caloric and nutritional therapy as orderedA. Initiating caloric and nutritional therapy as orderedB. Instituting behavioral modification therapy as orderedC. Addressing the client's low self-esteemD. Regularly monitoring vital signs and weight

Rationale: The client with anorexia nervosa is at risk for death from self-starvation.Therefore, initiating caloric and nutritional therapy takes highest priority.Behavioral modification (in which client privileges depend on weight gain) andpsychoanalysis (which addresses the client's low self-esteem, guilt, anxiety, andfeelings of hopelessness and depression) are important aspects of care but aresecondary to stabilizing the client's physical condition. Monitoring vital signs andweight is important in evaluating nutritional therapy but doesn't take precedenceover providing adequate caloric intake to ensure survival

11. A client tells the nurse that he is having suicidal thoughts every day. Inconferring with the treatment team, the nurse should make which of the followingrecommendations?

A. A no-suicide contractB. Weekly outpatient therapyC. A second psychiatric opinionD. Intensive inpatient treatmentD. Intensive inpatient treatment

Rationale: Inpatient care is the best intervention for a client who is thinking aboutsuicide every day. Implementing a no-suicide contract is an important strategy,but this client requires additional care. Weekly therapy wouldn't provide the

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intensity of care that this case warrants. Obtaining a second opinion would taketime; this client requires immediate intervention.

12. Which of the following etiologic factors predispose a client to Tourettesyndrome?

A. No known etiologyB. Abnormalities in brain neurotransmitters, structural changes in basalB. Abnormalities in brain neurotransmitters, structural changes in basalganglia and caudate nucleus, and geneticsganglia and caudate nucleus, and geneticsC. Abnormalities in the structure and function of the ventriclesD. Environmental factors and birth-related trauma

Rationale: The etiology of Tourette syndrome includes genetics, abnormalities inneurotransmission, and structural changes in the basal ganglia and caudatenucleus. The ventricles in the brain, environmental factors, and birth traumaaren't involved.

13. A client is admitted for detoxification after a cocaine overdose. The client tellsthe nurse that he frequently uses cocaine but he can control his use if hechooses. Which coping mechanism is he using?

A. WithdrawalB. Logical thinkingC. RepressionD. DenialD. Denial

Rationale: Denial is an unconscious defense mechanism in which emotionalconflict and anxiety are avoided by refusing to acknowledge feelings, desires,impulses, or external facts that are consciously intolerable. Withdrawal is acommon response to stress, characterized by apathy. Logical thinking IS theability to think rationally and make responsible decisions, which would lead theclient to admitting the problem and seeking help. Repression is suppressing pastevents from the consciousness because of guilty association.

14. An 16-year-old boy is admitted to the facility after acting out his aggressionsinappropriately at school. Predisposing factors to the expression of aggressioninclude:

A. violence on television.A. violence on television.B. passive parents.C. an internal locus of control.

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D. a single-parent family

Rationale: Violence on television has been correlated with an increase inaggressive behavior. Passive parents contribute to acting-out behaviors but notspecifically to violence. An internal locus of control leads to a positive sense ofself-esteem and isn't related to violence or aggression. There is no directcorrelation between single-parent families and violence.

15. A client is brought to the emergency department after being beaten by herhusband, a prominent attorney. The nurse caring for this client understands that:

A. open boundaries are common in violent families.B. violence usually results from a power struggle.C. domestic violence and abuse span all socioeconomic classes.C. domestic violence and abuse span all socioeconomic classes.D. violent behavior is a genetic trait passed from one generation to the next.

Rationale: Domestic violence and abuse affect all socioeconomic classes.Closed boundaries and an imbalance of power, with one member having controlover the others, are common in violent families. Although violent behavior may bepassed from one generation to the next, it's a learned behavior, not a genetictrait.

16. On discharge after treatment for alcoholism, a client plans to take disulfiram(Antabuse) as prescribed. When teaching the client about this drug, the nurseemphasizes the need to:

A. avoid all products containing alcohol.A. avoid all products containing alcohol.B. adhere to concomitant vitamin B therapy.C. return for monthly blood drug level monitoring.D. limit alcohol consumption to a moderate level.

Rationale: To avoid severe adverse effects, the client taking disulfiram muststrictly avoid alcohol and all products that contain alcohol. Vitamin B therapy andblood monitoring aren't necessary during disulfiram therapy.

17. During a private conversation, a client with borderline personality disorderasks the nurse to keep his secret and then displays multiple, self-inflicted,superficial lacerations on the forearms. What is the nurse's best response?

A. "That's it! You're on suicide precautions."B. "I'm going to tell your physician. Do you want to tell me why you did that?"C. "Tell me what type of instrument you used. I'm concerned about infection."

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D. "The team needs to know when something important occurs inD. "The team needs to know when something important occurs in

treatment. I need to tell the others, but let's talk about it first."treatment. I need to tell the others, but let's talk about it first."

Rationale: This response informs the client of the nurse's planned actions andallows time to discuss the client's actions. Options A and B put the client on thedefensive and may lead to a power struggle. Option C ignores the psychologicalimplications of the client's actions.

18. The nurse is providing care for a client undergoing opiate withdrawal. Opiatewithdrawal causes severe physical discomfort and can be life-threatening. Tominimize these effects, opiate users are commonly detoxified with:

A. barbiturates.B. amphetamines.

C. methadone.C. methadone.D. benzodiazepines.

Rationale: Methadone is used to detoxify opiate users because it binds withopioid receptors at many sites in the central nervous system but doesn't have thesame deleterious effects as other opiates, such as cocaine, heroin, andmorphine. Barbiturates, amphetamines, and benzodiazepines are highlyaddictive and would require detoxification treatment.

19. The nurse is caring for a client who she believes has been abusing opiates.Assessment findings in a client abusing opiates such as morphine include:

A. dilated pupils and slurred speech.B. rapid speech and agitation.C. dilated pupils and agitation.D. euphoria and constricted pupils.D. euphoria and constricted pupils.

Rationale: Assessment findings in a client abusing opiates include agitation,slurred speech, euphoria, and constricted pupils.

20. Which of the following signs should the nurse expect in a client with knownamphetamine overdose?

A. Hypotension

B. TachycardiaB. TachycardiaC. Hot, dry skin

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D. Constricted pupils

Rationale: Amphetamines are central nervous system stimulants. They causesympathetic stimulation, including hypertension, tachycardia, vasoconstriction,and hyperthermia. Hot, dry skin is seen with anticholinergic agents such asjimsonweed. Pupils will be dilated, not constricted.

21. A client is admitted to the psychiatric unit with a diagnosis of alcoholintoxication and suspected alcohol dependence. Other assessment findingsinclude an enlarged liver, jaundice, lethargy, and rambling, incoherent speech.No other information about the client is available. After the nurse completes theinitial assessment, what is the first priority?

A. Instituting seizure precautions, obtaining frequent vital signs, andA. Instituting seizure precautions, obtaining frequent vital signs, andrecording fluid intake and outputrecording fluid intake and outputB. Checking the client's medical records for health history informationC. Attempting to contact the client's family to obtain more information about theclientD. Restricting fluids and leaving the client alone to "sleep off" the episode

Rationale: A nurse who lacks adequate information to determine which level ofcare a client requires must take all possible precautions to ensure the client'sphysical safety and prevent complications. To do otherwise could place theclient at risk for potential complications. After taking all possible precautions, thenurse can begin seeking health history information and, as needed, modify theplan of care. Fluids are typically increased unless contraindicated by apreexisting medical condition.

22. Which nursing action is best when trying to diffuse a client's impendingviolent behavior?

A. Helping the client identify and express feelings of anxiety and angerA. Helping the client identify and express feelings of anxiety and angerB. Involving the client in a quiet activity to divert attentionC. Leaving the client alone until the client can talk about feelingsD. Placing the client in seclusion

Rationale: In many instances, the nurse can diffuse impending violence byhelping the client identify and express feelings of anger and anxiety. Suchstatements as "What happened to get you this angry?" may help the clientverbalize feelings rather than act on them. Close interaction with the client in aquiet activity may place the nurse at risk for injury should the client suddenly

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become violent. An agitated and potentially violent client shouldn't be left alone

or unsupervised because the danger of the client acting out is too great. Theclient should be placed in seclusion only if other interventions fail or the clientrequests this. Unlocked seclusion can be helpful for some clients because itreduces environmental stimulation and provides a feeling of security.

23. The nurse is working with a client who abuses alcohol. Which of the followingfacts should the nurse communicate to the client?

A. Abstinence is the basis for successful treatment.A. Abstinence is the basis for successful treatment.B. Attendance at Alcoholics Anonymous meetings every day will cure alcoholism.C. For treatment to be successful, family members must participate.D. An occasional social drink is acceptable behavior for the alcoholic

Rationale: The foundation of any treatment for alcoholism is abstinence.Attendance at Alcoholics Anonymous is helpful to some individuals to maintainstrict abstinence. Participation in treatment by the family is beneficial to both theclient and the family but isn't essential. Abstinence requires refraining from socialdrinking.

24. Which psychosocial influence has been causally related to the developmentof aggressive behavior and conduct disorder?

A. An overbearing motherB. Rejection by peersB. Rejection by peersC. A history of schizophrenia in the familyD. Low socioeconomic status

Rationale: Studies indicate that children who are rejected by their peers are morelikely to behave aggressively. Aggression and conduct disorder are representedin all socioeconomic groups. Schizophrenia and an overbearing mother haven'tbeen associated with aggression or conduct disorder

25. In group therapy, a client who has used I.V. heroin every day for the past 14years says, "I don't have a drug problem. I can quit whenever I want. I've done itbefore." Which defense mechanism is the client using?

A. DenialA. DenialB. ObsessionC. Compensation

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D. Rationalization

Rationale: A client who states that he or she doesn't have a drug problem andcan quit using drugs at any time — despite evidence to the contrary — isdenying the drug addiction. Obsession isn't a defense mechanism. Incompensation, the client emphasizes positive attributes to compensate fornegative ones. In rationalization, the client justifies behaviors by faulty logic.

26. A client with a history of cocaine addiction is admitted to the coronary careunit for evaluation of substernal chest pain. The electrocardiogram (ECG) showsa 1-mm ST-segment elevation the anteroseptal leads and T-wave inversion inleads V3 to V5. Considering the client's history of drug abuse, the nurse expectsthe physician to prescribe:

A. lidocaine (Xylocaine).B. procainamide (Pronestyl).

C. nitroglycerin (Nitro-Bid IV).C. nitroglycerin (Nitro-Bid IV).D. epinephrine.

Rationale: The elevated ST segments in this client's ECG indicate myocardialischemia. To reverse this problem, the physician is most likely to prescribe aninfusion of nitroglycerin to dilate the coronary arteries. Lidocaine andprocainamide are cardiac drugs that may be indicated for this client at somepoint but aren't used for coronary artery dilation. If a cocaine user experiencesventricular fibrillation or asystole, the physician may prescribe epinephrine.However, this drug must be used with caution because cocaine may potentiateits adrenergic effects.

27. A 15-year-old client is brought to the clinic by her mother. Her motherexpresses concern about her daughter's weight loss and constant dieting. Thenurse conducts a health history interview. Which of the following commentsindicates that the client may be suffering from anorexia nervosa?

A. "I like the way I look. I just need to keep my weight down because I'm acheerleader."B. "I don't like the food my mother cooks. I eat plenty of fast food when I'm outwith my friends."C. "I just can't seem to get down to the weight I want to be. I'm so fatC. "I just can't seem to get down to the weight I want to be. I'm so fatcompared to other girls."compared to other girls."

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D. "I do diet around my periods; otherwise, I just get so bloated."

Rationale: Low self-esteem is the highest risk factor for anorexia nervosa.Constant dieting to get down to a "desirable weight" is characteristic of thedisorder. Feeling inadequate when compared to peers indicates poor self-esteem. Most clients with anorexia nervosa don't like the way they look, and theirself-perception may be distorted. A girl with cachexia may perceive herself to beoverweight when she looks in the mirror. Preferring fast food over healthy food iscommon in this age-group. Because of the absence of body fat necessary forproper hormone production, amenorrhea is common in a client with anorexianervosa.

28. Which is the drug of choice for treating Tourette syndrome?

A. fluoxetine (Prozac)B. fluvoxamine (Luvox)C. haloperidol (Haldol)C. haloperidol (Haldol)D. paroxetine (Paxil)

Rationale: Haloperidol is the drug of choice for treating Tourette syndrome.Prozac, Luvox, and Paxil are antidepressants and aren't used to treat Tourettesyndrome

29. The client tells the nurse he was involved in a car accident while he wasintoxicated. What would be the most therapeutic response from the nurse?

A. "Why didn't you get someone else to drive you?"

B. "Tell me how you feel about the accident."B. "Tell me how you feel about the accident."C. "You should know better than to drink and drive."D. "I recommend that you attend an Alcoholics Anonymous meeting."

Rationale: An open-ended statement or question is the most therapeuticresponse. It encourages the widest range of client responses, makes the clientan active participant in the conversation, and shows the client that the nurse isinterested in his feelings. Asking the client why he drove while intoxicated canmake him feel defensive and intimidated. A judgmental approach isn'ttherapeutic. By giving advice, the nurse suggests that the client isn't capable ofmaking decisions, thus fostering dependency.

30. A client voluntarily admits himself to the substance abuse unit. He confesses

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that he drinks 1 qt or more of vodka each day and uses cocaine occasionally.Later that afternoon, he begins to show signs of alcohol withdrawal. What aresome early signs of this condition?

A. Vomiting, diarrhea, and bradycardiaB. Dehydration, temperature above 101° F (38.3° C), and pruritusC. Hypertension, diaphoresis, and seizuresD. Diaphoresis, tremors, and nervousnessD. Diaphoresis, tremors, and nervousness

Rationale: Alcohol withdrawal syndrome includes alcohol withdrawal, alcoholichallucinosis, and alcohol withdrawal delirium (formerly delirium tremens). Signs ofalcohol withdrawal include diaphoresis, tremors, nervousness, nausea, vomiting,malaise, increased blood pressure and pulse rate, sleep disturbance, andirritability. Although diarrhea may be an early sign of alcohol withdrawal,tachycardia — not bradycardia — is associated with alcohol withdrawal.Dehydration and an elevated temperature may be expected, but a temperatureabove 101° F indicates an infection rather than alcohol withdrawal. Pruritus rarelyoccurs in alcohol withdrawal. If withdrawal symptoms remain untreated, seizuresmay arise later.

31. When monitoring a client recently admitted for treatment of cocaineaddiction, the nurse notes sudden increases in the arterial blood pressure andheart rate. To correct these problems, the nurse expects the physician toprescribe:

A. norepinephrine (Levophed) and lidocaine (Xylocaine).B. nifedipine (Procardia) and lidocaine.C. nitroglycerin (Nitro-Bid IV) and esmolol (Brevibloc).D. nifedipine and esmololD. nifedipine and esmolol

Rationale: This client requires a vasodilator, such as nifedipine, to treathypertension, and a beta-adrenergic blocker, such as esmolol, to reduce theheart rate. Lidocaine, an antiarrhythmic, isn't indicated because the client doesn'thave an arrhythmia. Although nitroglycerin may be used to treat coronaryvasospasm, it isn't the drug of choice in hypertension.

32. A client experiencing alcohol withdrawal is upset about going throughdetoxification. Which of the following goals is a priority?

A. The client will commit to a drug-free lifestyle.

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B. The client will work with the nurse to remain safe.B. The client will work with the nurse to remain safe.C. The client will drink plenty of fluids daily.D. The client will make a personal inventory of strengths

Rationale: The priority goal in alcohol withdrawal is maintaining the client's safety.Committing to a drug-free lifestyle, drinking plenty of fluids, and identifyingpersonal strengths are important goals, but ensuring the client's safety is thenurse's top priority.

33. A client is admitted to a psychiatric facility by court order for evaluation forantisocial personality disorder. This client has a long history of initiating fightsand abusing animals and recently was arrested for setting a neighbor's dog onfire. When evaluating this client for the potential for violence, the nurse shouldassess for which behavioral clues?

A. A rigid posture, restlessness, and glaringA. A rigid posture, restlessness, and glaringB. Depression and physical withdrawalC. Silence and noncomplianceD. Hypervigilance and talk of past violent acts

Rationale: Behavioral clues that suggest the potential for violence include a rigidposture, restlessness, glaring, a change in usual behavior, clenched hands,overtly aggressive actions, physical withdrawal, noncompliance, overreaction,hostile threats, recent alcohol ingestion or drug use, talk of past violent acts,inability to express feelings, repetitive demands and complaints,argumentativeness, profanity, disorientation, inability to focus attention,hallucinations or delusions, paranoid ideas or suspicions, and somaticcomplaints. Violent clients rarely exhibit depression, silence, or hypervigilance.

34. A client is brought to the psychiatric clinic by family members, who tell theadmitting nurse that the client repeatedly drives while intoxicated despite theirpleas to stop. During an interview with the nurse, which statement by the clientmost strongly supports a diagnosis of psychoactive substance abuse?

A. "I'm not addicted to alcohol. In fact, I can drink more than I used to withoutbeing affected."B. "I only spend half of my paycheck at the bar."C. "I just drink to relax after work."D. "I know I've been arrested three times for drinking and driving, butD. "I know I've been arrested three times for drinking and driving, butthe police are just trying to hassle me."the police are just trying to hassle me."

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Rationale: According to the Diagnostic and Statistical Manual of MentalDisorders, 4th edition, diagnostic criteria for psychoactive substance abuseinclude a maladaptive pattern of such use, indicated either by continued use

despite knowledge of having a persistent or recurrent social, occupational,psychological, or physical problem caused or exacerbated by substance abuseor recurrent use in dangerous situations (for example, while driving). For thisclient, psychoactive substance dependence must be ruled out; criteria for thisdisorder include a need for increasing amounts of the substance to achieveintoxication (option A), increased time and money spent on the substance (optionB), inability to fulfill role obligations (option C), and typical withdrawal symptoms.

35. A client with borderline personality disorder is admitted to the psychiatricunit. Initial nursing assessment reveals that the client's wrists are scratched froma recent suicide attempt. Based on this finding, the nurse should formulate anursing diagnosis of:

A. Ineffective individual coping related to feelings of guilt.B. Situational low self-esteem related to feelings of loss of control.C. Risk for violence: Self-directed related to impulsive mutilating acts.C. Risk for violence: Self-directed related to impulsive mutilating acts.D. Risk for violence: Directed toward others related to verbal threats.

Rationale: The predominant behavioral characteristic of the client with borderlinepersonality disorder is impulsiveness, especially of a physically self-destructivesort. The observation that the client has scratched wrists doesn't substantiate theother options.

36. A client recently admitted to the hospital with sharp, substernal chest painsuddenly complains of palpitations. The nurse notes a rise in the client's arterialblood pressure and a heart rate of 144 beats/minute. On further questioning, theclient admits to having used cocaine recently after previously denying use of thedrug. The nurse concludes that the client is at high risk for which complication ofcocaine use?

A. Coronary artery spasmA. Coronary artery spasmB. BradyarrhythmiasC. Neurobehavioral deficitsD. Panic disorder

Rationale: Cocaine use may cause such cardiac complications as coronary

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artery spasm, myocardial infarction, dilated cardiomyopathy, acute heart failure,endocarditis, and sudden death. Cocaine blocks reuptake of norepinephrine,epinephrine, and dopamine, causing an excess of these neurotransmitters atpostsynaptic receptor sites. Consequently, the drug is more likely to cause

tachyarrhythmias than bradyarrhythmias. Although neurobehavioral deficits arecommon in neonates born to cocaine users, they are rare in adults. As cravingfor the drug increases, a person who's addicted to cocaine typically experienceseuphoria followed by depression, not panic disorder.

37. A client is being admitted to the substance abuse unit for alcoholdetoxification. As part of the intake interview, the nurse asks him when he had hislast alcoholic drink. He says that he had his last drink 6 hours before admission.Based on this response, the nurse should expect early withdrawal symptoms to:

A. begin after 7 days.B. not occur at all because the time period for their occurrence has passed.C. begin anytime within the next 1 to 2 days.C. begin anytime within the next 1 to 2 days.D. begin within 2 to 7 days.

Rationale: Acute withdrawal symptoms from alcohol may begin 6 hours after theclient has stopped drinking and peak 1 to 2 days later. Delirium tremens mayoccur 2 to 4 days — even up to 7 days — after the last drink.

38. The nurse is assigned to care for a client with anorexia nervosa. Initially,which nursing intervention is most appropriate for this client?

A. Providing one-on-one supervision during meals and for 1 hourA. Providing one-on-one supervision during meals and for 1 hourafterwardafterwardB. Letting the client eat with other clients to create a normal mealtimeatmosphereC. Trying to persuade the client to eat and thus restore nutritional balanceD. Giving the client as much time to eat as desired

Rationale: Because the client with anorexia nervosa may discard food or inducevomiting in the bathroom, the nurse should provide one-on-one supervisionduring meals and for 1 hour afterward. Option B wouldn't be therapeutic becauseother clients may urge the client to eat and give attention for not eating. Option Cwould reinforce control issues, which are central to this client's underlyingpsychological problem. Instead of giving the client unlimited time to eat, as inoption D, the nurse should set limits and let the client know what is expected.

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39. A client begins to experience alcoholic hallucinosis. What is the best nursingintervention at this time?

A. Keeping the client restrained in bed

B. Checking the client's blood pressure every 15 minutes and offering juicesC. Providing a quiet environment and administering medication asC. Providing a quiet environment and administering medication asneeded and prescribedneeded and prescribedD. Restraining the client and measuring blood pressure every 30 minutes

Rationale: Manifestations of alcoholic hallucinosis are best treated by providing aquiet environment to reduce stimulation and administering prescribed centralnervous system depressants in dosages that control symptoms without causingoversedation. Although bed rest is indicated, restraints are unnecessary unlessthe client poses a danger to himself or others. Also, restraints may increaseagitation and make the client feel trapped and helpless when hallucinating.Offering juice is appropriate, but measuring blood pressure every 15 minuteswould interrupt the client's rest. To avoid overstimulating the client, the nurseshould check blood pressure every 2 hours.

40. Which assessment finding is most consistent with early alcohol withdrawal?

A. Heart rate of 120 to 140 beats/minuteA. Heart rate of 120 to 140 beats/minuteB. Heart rate of 50 to 60 beats/minuteC. Blood pressure of 100/70 mm HgD. Blood pressure of 140/80 mm Hg

Rationale: Tachycardia, a heart rate of 120 to 140 beats/minute, is a commonsign of alcohol withdrawal. Blood pressure may be labile throughout withdrawal,fluctuating at different stages. Hypertension typically occurs in early withdrawal.Hypotension, although rare during the early withdrawal stages, may occur in laterstages. Hypotension is associated with cardiovascular collapse and mostcommonly occurs in clients who don't receive treatment. The nurse shouldmonitor the client's vital signs carefully throughout the entire alcohol withdrawalprocess.

41. Which client is at highest risk for suicide?

A. One who appears depressed, frequently thinks of dying, and gives away allpersonal possessionsB. One who plans a violent death and has the means readily availableB. One who plans a violent death and has the means readily available

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C. One who tells others that he or she might do something if life doesn't getbetter soonD. One who talks about wanting to die

Rationale: The client at highest risk for suicide is one who plans a violent death(for example, by gunshot, jumping off a bridge, or hanging), has a specific plan(for example, after the spouse leaves for work), and has the means readilyavailable (for example, a rifle hidden in the garage). A client who gives awaypossessions, thinks about death, or talks about wanting to die or attemptingsuicide is considered at a lower risk for suicide because this behavior typicallyserves to alert others that the client is contemplating suicide and wishes to behelped.

42. Which of the following medical conditions is commonly found in clients withbulimia nervosa?

A. AllergiesB. CancerC. Diabetes mellitusC. Diabetes mellitusD. Hepatitis A

Rationale: Bulimia nervosa can lead to many complications, including diabetes,heart disease, and hypertension. The eating disorder isn't typically associatedwith allergies, cancer, or hepatitis A.

43. A high school student is referred to the school nurse for suspectedsubstance abuse. Following the nurse's assessment and interventions, whatwould be the most desirable outcome?

A. The student discusses conflicts over drug use.

B. The student accepts a referral to a substance abuse counselor.B. The student accepts a referral to a substance abuse counselor.C. The student agrees to inform his parents of the problem.D. The student reports increased comfort with making choices.

Rationale: All of the outcomes stated are desirable; however, the best outcome isthat the student would agree to seek the assistance of a professional substanceabuse counselor.

44. A client who reportedly consumes 1 qt of vodka daily is admitted for alcoholdetoxification. To try to prevent alcohol withdrawal symptoms, the physician is

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most likely to prescribe which drug?

A. clozapine (Clozaril)B. thiothixene (Navane)C. lorazepam (Ativan)C. lorazepam (Ativan)

D. lithium carbonate (Eskalith)

Rationale: The best choice for preventing or treating alcohol withdrawalsymptoms is lorazepam, a benzodiazepine. Clozapine and thiothixene areantipsychotic agents, and lithium carbonate is an antimanic agent; these drugsaren't used to manage alcohol withdrawal syndrome.

45. A client is being treated for alcoholism. After a family meeting, the client'sspouse asks the nurse about ways to help the family deal with the effects ofalcoholism. The nurse should suggest that the family join which organization?

A. Al-AnonA. Al-AnonB. Make Today CountC. Emotions AnonymousD. Alcoholics Anonymous

Rationale: Al-Anon is an organization that assists family members to sharecommon experiences and increase their understanding of alcoholism. MakeToday Count is a support group for people with life-threatening or chronicillnesses. Emotions Anonymous is a support group for people experiencingdepression, anxiety, or similar conditions. Alcoholics Anonymous is anorganization that helps alcoholics recover by using a twelve-step program.

46. A client is admitted to the psychiatric clinic for treatment of anorexia nervosa.To promote the client's physical health, the nurse should plan to:

A. severely restrict the client's physical activities.B. weigh the client daily, after the evening meal.

C. monitor vital signs, serum electrolyte levels, and acid-base balance.C. monitor vital signs, serum electrolyte levels, and acid-base balance.D. instruct the client to keep an accurate record of food and fluid intake.

Rationale: An anorexic client who requires hospitalization is in poor physicalcondition from starvation and may die as a result of arrhythmias, hypothermia,malnutrition, infection, or cardiac abnormalities secondary to electrolyteimbalances. Therefore, monitoring the client's vital signs, serum electrolyte level,

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and acid base balance is crucial. Option A may worsen anxiety. Option B isincorrect because a weight obtained after breakfast is more accurate than oneobtained after the evening meal. Option D would reward the client with attentionfor not eating and reinforce the control issues that are central to the underlyingpsychological problem; also, the client may record food and fluid intake

inaccurately.

47. A young man is remanded by the courts for psychiatric treatment. His policerecord, which dates to his early teenage years, includes delinquency, runningaway, auto theft, and vandalism. He dropped out of school at age 16 and hasbeen living on his own since then. His history suggests maladaptive coping,which is associated with:

A. antisocial personality disorder.A. antisocial personality disorder.B. borderline personality disorder.C. obsessive-compulsive personality disorder.D. narcissistic personality disorder.

Rationale: The client's history of delinquency, running away from home,vandalism, and dropping out of school are characteristic of antisocial personalitydisorder. This maladaptive coping pattern is manifested by a disregard forsocietal norms of behavior and an inability to relate meaningfully to others. Inborderline personality disorder, the client exhibits mood instability, poor self-image, identity disturbance, and labile affect. Obsessive-compulsive personalitydisorder is characterized by a preoccupation with impulses and thoughts that theclient realizes are senseless but can't control. Narcissistic personality disorder ismarked by a pattern of self-involvement, grandiosity, and demand for constantattention.

48. A husband and wife seek emergency crisis intervention because he slappedher repeatedly the night before. The husband indicates that his childhood wasmarred by an abusive relationship with his father. When intervening with thiscouple, the nurse knows they are at risk for repeated violence because thehusband:

A. has only moderate impulse control.B. denies feelings of jealousy or possessiveness.C. has learned violence as an acceptable behavior.C. has learned violence as an acceptable behavior.D. feels secure in his relationship with his wife.

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Rationale: Family violence usually is a learned behavior, and violence typicallyleads to further violence, putting this couple at risk. Repeated slapping mayindicate poor, not moderate, impulse control. Violent people commonly arejealous and possessive and feel insecure in their relationships.

49. A client whose husband just left her has a recurrence of anorexia nervosa.The nurse caring for her realizes that this exacerbation of anorexia nervosaresults from the client's effort to:

A. manipulate her husband.

B. gain control of one part of her life.B. gain control of one part of her life.C. commit suicide.D. live up to her mother's expectations.

Rationale: By refusing to eat, a client with anorexia nervosa is unconsciouslyattempting to gain control over the only part of her life she feels she can control.This eating disorder doesn't represent an attempt to manipulate others or live upto their expectations (although anorexia nervosa has a high incidence in familiesthat emphasize achievement). The client isn't attempting to commit suicidethrough starvation; rather, by refusing to eat, she is expressing feelings ofdespair, worthlessness, and hopelessness.

50. A client has approached the nurse asking for advice on how to deal with hisalcohol addiction. The nurse should tell the client that the only effective treatmentfor alcoholism is:

A. psychotherapy.B. total abstinence.B. total abstinence.C. Alcoholics Anonymous (AA).D. aversion therapy.

Rationale: Total abstinence is the only effective treatment for alcoholism.Psychotherapy, attendance at AA meetings, and aversion therapy are alladjunctive therapies that can support the client in his efforts to abstain.

51. Flumazenil (Romazicon) has been ordered for a client who has overdosed onoxazepam (Serax). Before administering the medication, the nurse should beprepared for which common adverse effect?

A. SeizuresA. Seizures

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B. ShiveringC. AnxietyD. Chest pain

Rationale: Seizures are the most common serious adverse effect of usingflumazenil to reverse benzodiazepine overdose. The effect is magnified if the

client has a combined tricyclic antidepressant and benzodiazepine overdose.Less common adverse effects include shivering, anxiety, and chest pain.

52. The nurse is caring for a client diagnosed with bulimia. The most appropriateinitial goal for a client diagnosed with bulimia is to:

A. avoid shopping for large amounts of food.B. control eating impulses.C. identify anxiety-causing situations.C. identify anxiety-causing situations.D. eat only three meals per day.

Rationale: Bulimic behavior is generally a maladaptive coping response to stressand underlying issues. The client must identify anxiety-causing situations thatstimulate the bulimic behavior and then learn new ways of coping with theanxiety. Controlling shopping for large amounts of food isn't a goal early intreatment. Managing eating impulses and replacing them with adaptive copingmechanisms can be integrated into the plan of care after initially addressingstress and underlying issues. Eating three meals per day isn't a realistic goalearly in treatment.

53. A client who's at high risk for suicide needs close supervision. To best ensurethe client's safety, the nurse should:

A. check the client frequently at irregular intervals throughout the night.A. check the client frequently at irregular intervals throughout the night.B. assure the client that the nurse will hold in confidence anything the client says.C. repeatedly discuss previous suicide attempts with the client.D. disregard decreased communication by the client because this is common insuicidal clients.

Rationale: Checking the client frequently but at irregular intervals prevents theclient from predicting when observation will take place and altering behavior in amisleading way at these times. Option B may encourage the client to try tomanipulate the nurse or seek attention for having a secret suicide plan. Option Cmay reinforce suicidal ideas. Decreased communication is a sign of withdrawal

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that may indicate the client has decided to commit suicide; the nurse shouldn'tdisregard it (option D

54. Which of the following drugs should the nurse prepare to administer to aclient with a toxic acetaminophen (Tylenol) level?

A. deferoxamine mesylate (Desferal)

B. succimer (Chemet)C. flumazenil (Romazicon)D. acetylcysteine (Mucomyst)D. acetylcysteine (Mucomyst)

Rationale: The antidote for acetaminophen toxicity is acetylcysteine. It enhancesconversion of toxic metabolites to nontoxic metabolites. Deferoxamine mesylateis the antidote for iron intoxication. Succimer is an antidote for lead poisoning.Flumazenil reverses the sedative effects of benzodiazepines.

55. A client is admitted to the substance abuse unit for alcohol detoxification.Which of the following medications is the nurse most likely to administer toreduce the symptoms of alcohol withdrawal?

A. naloxone (Narcan)B. haloperidol (Haldol)C. magnesium sulfateD. chlordiazepoxide (Librium)D. chlordiazepoxide (Librium)

Rationale: Chlordiazepoxide (Librium) and other tranquilizers help reduce thesymptoms of alcohol withdrawal. Haloperidol (Haldol) may be given to treatclients with psychosis, severe agitation, or delirium. Naloxone (Narcan) isadministered for narcotic overdose. Magnesium sulfate and other anticonvulsantmedications are only administered to treat seizures if they occur duringwithdrawal.56. During postprandial monitoring, a client with bulimia nervosa tells the nurse,"You can sit with me, but you're just wasting your time. After you sat with meyesterday, I was still able to purge. Today, my goal is to do it twice." What is thenurse's best response?

A. "I trust you not to purge."B. "How are you purging and when do you do it?"C. "Don't worry. I won't allow you to purge today."

D. "I know it's important for you to feel in control, but I'll monitor you forD. "I know it's important for you to feel in control, but I'll monitor you for

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90 minutes after you eat."90 minutes after you eat."

Rationale: This response acknowledges that the client is testing limits and thatthe nurse is setting them by performing postprandial monitoring to prevent self-induced emesis. Clients with bulimia nervosa need to feel in control of the dietbecause they feel they lack control over all other aspects of their lives. Because

their therapeutic relationships with caregivers are less important than their needto purge, they don't fear betraying the nurse's trust by engaging in the activity.They commonly plot purging and rarely share their secrets about it. Anauthoritarian or challenging response may trigger a power struggle between thenurse and client.

57. A client admitted to the psychiatric unit for treatment of substance abusesays to the nurse, "It felt so wonderful to get high." Which of the following is themost appropriate response?

A. "If you continue to talk like that, I'm going to stop speaking to you."B. "You told me you got fired from your last job for missing too manyB. "You told me you got fired from your last job for missing too manydays after taking drugs all night."days after taking drugs all night."C. "Tell me more about how it felt to get high."D. "Don't you know it's illegal to use drugs?"

Rationale: Confronting the client with the consequences of substance abusehelps to break through denial. Making threats (option A) isn't an effective way topromote self-disclosure or establish a rapport with the client. Although the nurseshould encourage the client to discuss feelings, the discussion should focus onhow the client felt before, not during, an episode of substance abuse (option C).Encouraging elaboration about his experience while getting high may reinforcethe abusive behavior. The client undoubtedly is aware that drug use is illegal; areminder to this effect (option D) is unlikely to alter behavior.

58. For a client with anorexia nervosa, which goal takes the highest priority?

A. The client will establish adequate daily nutritional intake.A. The client will establish adequate daily nutritional intake.B. The client will make a contract with the nurse that sets a target weight.C. The client will identify self-perceptions about body size as unrealistic.D. The client will verbalize the possible physiological consequences of self-starvation.

Rationale: According to Maslow's hierarchy of needs, all humans need to meet

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basic physiological needs first. Because a client with anorexia nervosa eats littleor nothing, the nurse must first plan to help the client meet this basic, immediatephysiological need. The nurse may give lesser priority to goals that address long-term plans (as in option B), self-perception (as in option C), and potentialcomplications (as in option D).

59. When interviewing the parents of an injured child, which of the following is thestrongest indicator that child abuse may be a problem?

A. The injury isn't consistent with the history or the child's age.A. The injury isn't consistent with the history or the child's age.B. The mother and father tell different stories regarding what happened.C. The family is poor.D. The parents are argumentative and demanding with emergency departmentpersonnel.

Rationale: When the child's injuries are inconsistent with the history given orimpossible because of the child's age and developmental stage, the emergencydepartment nurse should be suspicious that child abuse is occurring. Theparents may tell different stories because their perception may be differentregarding what happened. If they change their story when different health careworkers ask the same question, this is a clue that child abuse may be a problem.Child abuse occurs in all socioeconomic groups. Parents may argue and bedemanding because of the stress of having an injured child.

60. For a client with anorexia nervosa, the nurse plans to include the parents intherapy sessions along with the client. What fact should the nurse remember tobe typical of parents of clients with anorexia nervosa?

A. They tend to overprotect their children.A. They tend to overprotect their children.B. They usually have a history of substance abuse.C. They maintain emotional distance from their children.D. They alternate between loving and rejecting their children.

Rationale: Clients with anorexia nervosa typically come from a family with parentswho are controlling and overprotective. These clients use eating to gain control ofan aspect of their lives. The characteristics described in options B, C, and Daren't typical of parents of children with anorexia.

61. In the emergency department, a client with facial lacerations states that herhusband beat her with a shoe. After the health care team repairs her lacerations,she waits to be seen by the crisis intake nurse, who will evaluate the continued

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threat of violence. Suddenly the client's husband arrives, shouting that he wantsto "finish the job." What is the first priority of the health care worker who witnessesthis scene?

A. Remaining with the client and staying calmB. Calling a security guard and another staff member for assistanceB. Calling a security guard and another staff member for assistanceC. Telling the client's husband that he must leave at onceD. Determining why the husband feels so angry

Rationale: The health care worker who witnesses this scene must takeprecautions to ensure personal as well as client safety, but shouldn't attempt tomanage a physically aggressive person alone. Therefore, the first priority is tocall a security guard and another staff member. After doing this, the health careworker should inform the husband what is expected, speaking in concisestatements and maintaining a firm but calm demeanor. This approach makes itclear that the health care worker is in control and may diffuse the situation untilthe security guard arrives. Telling the husband to leave would probably beineffective because of his agitated and irrational state. Exploring his angerdoesn't take precedence over safeguarding the client and staff.

62. The nurse is caring for a client with bulimia. Strict management of dietaryintake is necessary. Which intervention is also important?

A. Fill out the client's menu and make sure she eats at least half of what is on hertray.B. Let the client eat her meals in private. Then engage her in social activities forat least 2 hours after each meal.C. Let the client choose her own food. If she eats everything she orders,C. Let the client choose her own food. If she eats everything she orders,then stay with her for 1 hour after each meal.then stay with her for 1 hour after each meal.D. Let the client eat food brought in by the family if she chooses, but she shouldkeep a strict calorie count.

Rationale: Allowing the client to select her own food from the menu will help herfeel some sense of control. She must then eat 100% of what she selected.Remaining with the client for at least 1 hour after eating will prevent purging.Bulimic clients should only be allowed to eat food provided by the dietarydepartment.

63. The nurse is assigned to care for a suicidal client. Initially, which is thenurse's highest care priority?

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A. Assessing the client's home environment and relationships outside thehospitalB. Exploring the nurse's own feelings about suicideB. Exploring the nurse's own feelings about suicideC. Discussing the future with the clientD. Referring the client to a clergyperson to discuss the moral implications ofsuicide

Rationale: The nurse's values, beliefs, and attitudes toward self-destructivebehavior influence responses to a suicidal client; such responses set the overallmood for the nurse-client relationship. Therefore, the nurse initially must explorepersonal feelings about suicide to avoid conveying negative feelings to the client.Assessment of the client's home environment and relationships may reveal theneed for family therapy; however, conducting such an assessment isn't a nursingpriority. Discussing the future and providing anticipatory guidance can help theclient prepare for future stress, but this isn't a priority. Referring the client to aclergyperson may increase the client's trust or alleviate guilt; however, it isn't thehighest priority.

64. A client with anorexia nervosa tells the nurse, "When I look in the mirror, I hatewhat I see. I look so fat and ugly." Which strategy should the nurse use to dealwith the client's distorted perceptions and feelings?

A. Avoid discussing the client's perceptions and feelings.B. Focus discussions on food and weight.C. Avoid discussing unrealistic cultural standards regarding weight.D. Provide objective data and feedback regarding the client's weight andD. Provide objective data and feedback regarding the client's weight andattractiveness.attractiveness.

Rationale: By focusing on reality, this strategy may help the client develop a morerealistic body image and gain self-esteem. Option A is inappropriate becausediscussing the client's perceptions and feeling wouldn't help her to identify,accept, and work through them. Focusing discussions on food and weight wouldgive the client attention for not eating, making option B incorrect. Option C isinappropriate because recognizing unrealistic cultural standards wouldn't helpthe client establish more realistic weight goals.

65. The nurse is caring for a client being treated for alcoholism. Before initiatingtherapy with disulfiram (Antabuse), the nurse teaches the client that he must readlabels carefully on which of the following products?

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A. Carbonated beveragesB. Aftershave lotionB. Aftershave lotionC. ToothpasteD. Cheese

Rationale: Disulfiram may be given to clients with chronic alcohol abuse whowish to curb impulse drinking. Disulfiram works by blocking the oxidation of

alcohol, inhibiting the conversion of acetaldehyde to acetate. As acetaldehydebuilds up in the blood, the client experiences noxious and uncomfortablesymptoms. Even alcohol rubbed onto the skin can produce a reaction. The clientreceiving disulfiram must be taught to read ingredient labels carefully to avoidproducts containing alcohol such as aftershave lotions. Carbonated beverages,toothpaste, and cheese don't contain alcohol and don't need to be avoided bythe client.

66. The nurse is developing a plan of care for a client with anorexia nervosa.Which action should the nurse include in the plan?

A. Restrict visits with the family until the client begins to eat.B. Provide privacy during meals.C. Set up a strict eating plan for the client.C. Set up a strict eating plan for the client.D. Encourage the client to exercise, which will reduce her anxiety.

Rationale: Establishing a consistent eating plan and monitoring the client'sweight are important for this disorder. The family should be included in theclient's care. The client should be monitored during meals — not given privacy.Exercise must be limited and supervised.

67. Victims of domestic violence should be assessed for what importantinformation?

A. Reasons they stay in the abusive relationship (for example, lack of financialautonomy and isolation)B. Readiness to leave the perpetrator and knowledge of resourcesB. Readiness to leave the perpetrator and knowledge of resourcesC. Use of drugs or alcoholD. History of previous victimization

Rationale: Victims of domestic violence must be assessed for their readiness toleave the perpetrator and their knowledge of the resources available to them.Nurses can then provide the victims with information and options to enable them

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to leave when they are ready. The reasons they stay in the relationship arecomplex and can be explored at a later time. The use of drugs or alcohol isirrelevant. There is no evidence to suggest that previous victimization results in aperson's seeking or causing abusive relationships.

68. A client is hospitalized with fractures of the right femur and right humerussustained in a motorcycle accident. Police suspect the client was intoxicated atthe time of the accident. Laboratory tests reveal a blood alcohol level of 0.2%(200 mg/dl). The client later admits to drinking heavily for years. Duringhospitalization, the client periodically complains of tingling and numbness in thehands and feet. The nurse realizes that these symptoms probably result from:

A. acetate accumulation.B. thiamine deficiency.B. thiamine deficiency.C. triglyceride buildup.D. a below-normal serum potassium level

Rationale: Numbness and tingling in the hands and feet are symptoms ofperipheral polyneuritis, which results from inadequate intake of vitamin B1(thiamine) secondary to prolonged and excessive alcohol intake. Treatmentincludes reducing alcohol intake, correcting nutritional deficiencies through dietand vitamin supplements, and preventing such residual disabilities as foot andwrist drop. Acetate accumulation, triglyceride buildup, and a below-normalserum potassium level are unrelated to the client's symptoms.

69. A parent brings a preschooler to the emergency department for treatment ofa dislocated shoulder, which allegedly happened when the child fell down thestairs. Which action should make the nurse suspect that the child was abused?

A. The child cries uncontrollably throughout the examination.B. The child pulls away from contact with the physician.C. The child doesn't cry when the shoulder is examined.C. The child doesn't cry when the shoulder is examined.D. The child doesn't make eye contact with the nurse.

Rationale: A characteristic behavior of abused children is lack of crying whenthey undergo a painful procedure or are examined by a health care professional.Therefore, the nurse should suspect child abuse. Crying throughout theexamination, pulling away from the physician, and not making eye contact withthe nurse are normal behaviors for preschoolers.

70. When planning care for a client who has ingested phencyclidine (PCP),

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which of the following is the highest priority?

A. Client's physical needsB. Client's safety needsB. Client's safety needsC. Client's psychosocial needsD. Client's medical needs

Rationale: The highest priority for a client who has ingested PCP is meeting

safety needs of the client as well as the staff. Drug effects are unpredictable andprolonged, and the client may lose control easily. After safety needs have beenmet, the client's physical, psychosocial, and medical needs can be met.

71. Which outcome criteria would be appropriate for a child diagnosed withoppositional defiant disorder?

A. Accept responsibility for own behaviors.A. Accept responsibility for own behaviors.B. Be able to verbalize own needs and assert rights.C. Set firm and consistent limits with the client.D. Allow the child to establish his own limits and boundaries.

Rationale: Children with oppositional defiant disorder frequently violate the rightsof others. They are defiant, disobedient, and blame others for their actions.Accountability for their actions would demonstrate progress for the oppositionalchild. Options C and D aren't outcome criteria but interventions. Option B isincorrect as the oppositional child usually focuses on his own needs.

72. A client is found sitting on the floor of the bathroom in the day treatment clinicwith moderate lacerations on both wrists. Surrounded by broken glass, she sitsstaring blankly at her bleeding wrists while staff members call for an ambulance.How should the nurse approach her initially?

A. Enter the room quietly and move beside her to assess her injuries.B. Call for staff back-up before entering the room and restraining her.C. Move as much glass away from her as possible and sit next to her quietly.D. Approach her slowly while speaking in a calm voice, calling herD. Approach her slowly while speaking in a calm voice, calling hername, and telling her that the nurse is here to help her.name, and telling her that the nurse is here to help her.

Rationale: Ensuring the safety of the client and the nurse is the priority at thistime. Therefore, the nurse should approach the client cautiously while calling hername and talking to her in a calm, confident manner. The nurse should keep inmind that the client shouldn't be startled or overwhelmed. After explaining that

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the nurse is there to help, the nurse should observe the client's responsecarefully. If the client shows signs of agitation or confusion or poses a threat, thenurse should retreat and request assistance. The nurse shouldn't attempt to sitnext to the client or examine injuries without first announcing the nurse'spresence and assessing the dangers of the situation.

73. A client with anorexia nervosa describes herself as "a whale." However, thenurse's assessment reveals that the client is 5′ 8" (1.7 m) tall and weighs only 90lb (40.8 kg). Considering the client's unrealistic body image, which interventionshould be included in the plan of care?

A. Asking the client to compare her figure with magazine photographs of womenher ageB. Assigning the client to group therapy in which participants provide realisticfeedback about her weightC. Confronting the client about her actual appearance during one-on-onesessions, scheduled during each shiftD. Telling the client of the nurse's concern for her health and desire toD. Telling the client of the nurse's concern for her health and desire tohelp her make decisions to keep her healthyhelp her make decisions to keep her healthy

Rationale: A client with anorexia nervosa has an unrealistic body image thatcauses consumption of little or no food. Therefore, the client needs assistancewith making decisions about health. Instead of protecting the client's health,options A, B, and C may serve to make the client defensive and more entrenchedin her unrealistic body image.

74. Eighteen hours after undergoing an emergency appendectomy, a client witha reported history of social drinking displays these vital signs: temperature,101.6° F (38.7° C); heart rate, 126 beats/minute; respiratory rate, 24breaths/minute; and blood pressure, 140/96 mm Hg. The client exhibits grosshand tremors and is screaming for someone to kill the bugs in the bed. The nurseshould suspect:

A. a postoperative infection.B. alcohol withdrawal.B. alcohol withdrawal.C. acute sepsis.D. pneumonia.

Rationale: The client's vital signs and hallucinations suggest delirium tremens oralcohol withdrawal syndrome. Although infection, acute sepsis, and pneumonia

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may arise as postoperative complications, they wouldn't cause this client's signsand symptoms and typically would occur later in the postoperative course.

75. Clonidine (Catapres) can be used to treat conditions other than hypertension.For which of the following conditions might the drug be administered?

A. Phencyclidine (PCP) intoxicationB. Alcohol withdrawal

C. Opiate withdrawalC. Opiate withdrawalD. Cocaine withdrawal

Rationale: Clonidine is used as adjunctive therapy in opiate withdrawal.Benzodiazepines, such as chlordiazepoxide (Librium), and neuropleptic agents,such as haloperidol, are used to treat alcohol withdrawal. Benzodiazepines andneuropleptic agents are typically used to treat PCP intoxication. Antidepressantsand medications with dopaminergic activity in the brain, such as fluoxotine(Prozac), are used to treat cocaine withdrawal.

76. One of the goals for a client with anorexia nervosa is that the client willdemonstrate increased individual coping by responding to stress in constructiveways. Which of the following actions is the best indicator that the client is workingtoward meeting the goal?

A. The client drinks 4 L of fluid per day.B. The client paces around the unit most of the day.C. The client keeps a journal and discusses it with the nurse.C. The client keeps a journal and discusses it with the nurse.D. The client talks almost constantly with friends by telephone.

Rationale: The client is moving toward meeting the goal because recording anddiscussing feelings is a constructive way to manage stress. Although physicalactivity can reduce stress, the anorexic client is more likely to use pacing to burncalories and lose weight. Although talks with friends can decrease stress,constant talking is more likely a way of avoiding dealing with problems.Increased fluid intake may be an attempt by the client to curb her appetite andartificially increase her weight.

77. The nurse in the substance abuse unit is trying to encourage a client toattend Alcoholics Anonymous meetings. When the client asks the nurse what hemust do to become a member, the nurse should respond:

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A. "You must first stop drinking."B. "Your physician must refer you to this program."C. "Admit you're powerless over alcohol and that you need help."C. "Admit you're powerless over alcohol and that you need help."D. "You must bring along a friend who will support you."

Rationale: The first of the "Twelve Steps of Alcoholics Anonymous" is admittingthat an individual is powerless over alcohol and that life has becomeunmanageable. Although Alcoholics Anonymous promotes total abstinence, aclient will still be accepted if he drinks. A physician referral isn't necessary to join.New members are assigned a support person who may be called upon when theclient has the urge to drink.

78. An attorney who throws books and furniture around the office after losing acase is referred to the psychiatric nurse in the law firm's employee assistanceprogram. The nurse knows that the client's behavior most likely represents theuse of which defense mechanism?

A. RegressionA. RegressionB. ProjectionC. Reaction-formationD. Intellectualization

Rationale: An adult who throws temper tantrums, such as this one, is displayingregressive behavior, or behavior that is appropriate at a younger age. Inprojection, the client blames someone or something other than the source. Inreaction formation, the client acts in opposition to his feelings. Inintellectualization, the client overuses rational explanations or abstract thinking todecrease the significance of a feeling or event.

79. After completing chemical detoxification and a 12-step program to treatcrack addiction, a client is being prepared for discharge. Which remark by theclient indicates a realistic view of the future?

A. "I'm never going to use crack again."B. "I know what I have to do. I have to limit my crack use."C. "I'm going to take 1 day at a time. I'm not making any promises."C. "I'm going to take 1 day at a time. I'm not making any promises."D. "I will substitue crack for something else"

Rationale: Twelve-step programs focus on recovery 1 day at a time. Suchprograms discourage people from claiming that they will never again use asubstance, because relapse is common. The belief that one may use a limited

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amount of an abused substance indicates denial. Substituting one abusedsubstance for another predisposes the client to cross-addiction.

80. The nurse is assessing a client on admission to the chemical dependencyunit for alcohol detoxification. When the nurse asks about alcohol use, this clientis most likely to:

A. accurately describe the amount consumed.B. underestimate the amount consumed.B. underestimate the amount consumed.

C. overestimate the amount consumed.D. deny any consumption of alcohol.

Rationale: Most people who abuse substances underestimate their consumptionin an attempt to conform to social norms or protect themselves. Few accuratelydescribe or overestimate consumption; some may deny it. Therefore, onadmission, quantitative and qualitative toxicology screens are done to validateinformation obtained from the client.

81. The nurse is assessing a 15-year-old female who's being admitted fortreatment of anorexia nervosa. Which clinical manifestation is the nurse mostlikely to find?

A. TachycardiaB. Warm, flushed extremitiesC. Parotid gland tendernessC. Parotid gland tendernessD. Coarse hair growth

Rationale: Frequent vomiting causes tenderness and swelling of the parotidglands. The reduced metabolism that occurs with severe weight loss producesbradycardia and cold extremities. Soft, downlike hair (called lanugo) may coverthe extremities, shoulders, and face of an anorexic client.

82. A 38-year-old client is admitted for alcohol withdrawal. The most commonearly sign or symptom that this client is likely to experience is:

A. impending coma.B. manipulating behavior.C. suppression.D. perceptual disorders.D. perceptual disorders.

Rationale: Perceptual disorders, especially frightening visual hallucinations, are

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very common with alcohol withdrawal. Coma isn't an immediate consequence.Manipulative behaviors are part of the alcoholic client's personality but aren'tsigns of alcohol withdrawal. Suppression is a conscious effort to concealunacceptable thoughts, feelings, impulses, or acts and serves as a copingmechanism for most alcoholics.

83. The nurse is caring for an adolescent female who reports amenorrhea, weightloss, and depression. Which additional assessment finding would suggest thatthe woman has an eating disorder?

A. Wearing tight-fitting clothingB. Increased blood pressureC. Oily skinD. Excessive and ritualized exerciseD. Excessive and ritualized exercise

Rationale: A client with an eating disorder will normally exercise to excess in aneffort to burn as many calories as possible. The client will usually wear loose-fitting clothing to hide what she considers to be a fat body. Skin and nailsbecome dry and brittle and blood pressure and body temperature drop fromexcessive weight loss.

84. A client with a history of polysubstance abuse is admitted to the facility. Shecomplains of nausea and vomiting 24 hours after admission. The nurse assessesthe client and notes piloerection, pupillary dilation, and lacrimation. The nursesuspects that the client is going through which of the following withdrawals?

A. Alcohol withdrawalB. Cannibis withdrawalC. Cocaine withdrawalD. Opioid withdrawalD. Opioid withdrawal

Rationale: The symptoms listed are specific to opioid withdrawal. Alcoholwithdrawal would show elevated vital signs. There is no real withdrawal fromcannibis. Symptoms of cocaine withdrawal include depression, anxiety, andagitation.

85. A client is admitted to the psychiatric unit with a diagnosis of anorexianervosa. Although she is 5′ 8" (1.7 m) tall and weighs only 103 lb (46.7 kg), shetalks incessantly about how fat she is. Which measure should the nurse take firstwhen caring for this client?

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A. Teach the client about nutrition, calories, and a balanced diet.B. Establish a trusting relationship with the client.B. Establish a trusting relationship with the client.

C. Discuss cultural stereotypes regarding thinness and attractiveness.D. Explore the reasons why the client doesn't eat.

Rationale: A client with an eating disorder may be secretive and unwilling toadmit that a problem exists. Therefore, the nurse first must establish a trustingrelationship to elicit the client's feelings and thoughts. The anorexic client may

spend long hours discussing nutrition or handling and preparing food in an effortto stall or avoid eating food; the nurse shouldn't reinforce her preoccupation withfood, as in option A. Although cultural stereotypes may play a prominent role inanorexia nervosa, discussing these factors isn't the first action the nurse shouldtake. Exploring the reasons why the client doesn't eat would increase heremotional investment in food and eating.

86. A client is admitted for an overdose of amphetamines. When assessing thisclient, the nurse should expect to see:

A. tension and irritability.A. tension and irritability.B. slow pulse.C. hypotension.D. constipation.

Rationale: An amphetamine is a nervous system stimulant that is subject toabuse because of its ability to produce wakefulness and euphoria. An overdoseincreases tension and irritability. Options B and C are incorrect becauseamphetamines stimulate norepinephrine, which increases the heart rate andblood flow. Diarrhea is a common adverse effect, so option D is incorrect.

87. Which of the following drugs may be abused because of tolerance andphysiologic dependence.

A. lithium (Lithobid) and divalproex (Depakote).B. verapamil (Calan) and chlorpromazine (Thorazine)

C. alprazolam (Xanax) and phenobarbital (Luminal)C. alprazolam (Xanax) and phenobarbital (Luminal)D. clozapine (Clozaril) and amitriptyline (Elavil)

Rationale: Both benzodiazepines, such as alprazolam, and barbiturates, such as

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phenobarbital, are addictive, controlled substances. All the other drugs listedaren't addictive substances.

88. Which of the following groups are considered to be at highest risk forsuicide?

A. Adolescents, men over age 45, and persons who have made previousA. Adolescents, men over age 45, and persons who have made previoussuicide attemptssuicide attemptsB. Teachers, divorced persons, and substance abusersC. Alcohol abusers, widows, and young married men

D. Depressed persons, physicians, and persons living in rural areas

Rationale: Studies of those who commit suicide reveal the following high-riskgroups: adolescents; men over age 45; persons who have made previoussuicide attempts; divorced, widowed, and separated persons; professionals,such as physicians, dentists, and attorneys; students; unemployed persons;persons who are depressed, delusional, or hallucinating; alcohol or substanceabusers; and persons who live in urban areas. Although more women attemptsuicide than men, they typically choose less lethal means and therefore are lesslikely to succeed in their attempts.

89. Tourette syndrome is characterized by the presence of multiple motor andvocal tics. A vocal tic that involves repeating one's own sounds or words isknown as:

A. echolalia.

B. palilalia.B. palilalia.C. apraxia.D. aphonia.

Rationale: Palilalia is defined as the repetition of sounds and words. Echolalia isthe act of repeating the words of others. Apraxia is the inability to carry out motoractivities, and aphonia is the inability to speak