Question

A nurse is caring for a client who is receiving treatment for alcohol detoxification. Which of the following medications should the nurse expect to administer during this phase of the client's care?

Answer 1

Correct Answers:

Diazepam

Rationale :

💎 Diazepam, a benzodiazepine, is the drug of choice for managing alcohol detoxification because it helps prevent alcohol withdrawal symptoms, including seizures, tremors, and delirium tremens.

💎 It works by enhancing GABA activity, producing a calming effect on the central nervous system, which reduces hyperexcitability caused by alcohol withdrawal.

💎 Buprenorphine is used for opioid withdrawal, Varenicline for smoking cessation, and Rimonabant (no longer widely used) was for weight management.

💎 Diazepam also provides sedation and anxiety relief, promoting safer detoxification and stabilizing vital signs.

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Answer 2

Correct Answers:

Lanugo
Cold extremities
Hypotension

Rationale :

Lanugo

🔹 Lanugo is the fine, soft hair that develops on the body as a compensatory mechanism to maintain body heat due to severe loss of subcutaneous fat.

🔹 It is a classic physical finding in anorexia nervosa, reflecting prolonged malnutrition and extremely low body weight.

🔹 The appearance of lanugo indicates that the body is in a state of starvation, attempting to preserve core temperature.

🔹 Monitoring for lanugo helps in assessing the severity of malnutrition and guides the urgency of nutritional interventions.

Cold extremities

🔹 Cold hands and feet occur because of decreased body fat and poor peripheral circulation, secondary to low metabolic rate and hypotension.

🔹 Hypothermia is common in anorexia nervosa due to reduced caloric intake and slowed metabolism.

🔹 This finding highlights the body’s impaired thermoregulation and should prompt careful monitoring for hypothermia and circulatory compromise.

🔹 Nurses should ensure clients are kept warm and comfortable while initiating nutritional rehabilitation.

Hypotension

🔹 Low blood pressure results from dehydration, malnutrition, and decreased cardiac output in anorexia nervosa.

🔹 Chronic caloric restriction leads to muscle wasting, including cardiac muscle, causing bradycardia and hypotension.

🔹 Hypotension places the client at risk for syncope, dizziness, and falls, which require close monitoring.

🔹 This finding also reflects severe energy deficiency, necessitating nutritional support and cardiac monitoring during care.

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Answer 3

Correct Answers:

Verbally de-escalate the client.

Rationale :

💎 The first-line intervention for a client showing early signs of agitation (e.g., clenched jaw, anxious tone, increased tension) is verbal de-escalation.

💎 This involves using calm, clear, and non-threatening communication to help the client regain control before behavior escalates to violence.

💎 Early intervention with therapeutic communication can prevent the need for restrictive measures such as restraints or seclusion.

💎 Medications (e.g., haloperidol) and seclusion are used only when the client becomes a danger to self or others and less restrictive methods have failed.

💎 De-escalation preserves the client’s dignity and autonomy while maintaining safety.

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Answer 4

Correct Answers:

Fluctuating level of orientation

Rationale :

💥 Delirium is characterized by an acute onset of confusion, fluctuating orientation, and altered level of consciousness, often due to an underlying medical condition (e.g., heart failure, infection).

💥 Unlike dementia, which has a gradual and progressive memory loss, delirium develops suddenly and changes throughout the day.

💥 The nurse should promptly report this finding because delirium can indicate a serious, reversible medical condition requiring immediate treatment.

💥 Early recognition and intervention help prevent complications and restore baseline cognitive function.

💥 Obsessive behaviors or consistent depression are not primary indicators of delirium.

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Answer 5

Correct Answers:

Hypokalemia

Rationale :

💎 Hypokalemia (low potassium levels) is a common finding in bulimia nervosa due to frequent vomiting, laxative, or diuretic abuse, which causes potassium loss.

💎 This electrolyte imbalance can lead to muscle weakness, cardiac arrhythmias, and fatigue, making it a critical assessment finding.

💎 Lanugo and muscle wasting are more characteristic of anorexia nervosa, which involves severe prolonged malnutrition.

💎 Hypomagnesemia may occur but is less common than hypokalemia in bulimia.

💎 Early identification and correction of hypokalemia are essential to prevent life-threatening cardiac complications.

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Answer 6

Correct Answers:

Taking an experimental medication

Rationale :

📌 Informed consent is legally and ethically required when a client is undergoing treatments that involve significant risks, invasive procedures, or experimental therapies.

📌Taking an experimental medication requires the client to be fully informed about the purpose, potential risks, benefits, and alternative treatments before agreeing.

📌 Voluntary admission does not automatically imply consent for all treatments; the client maintains the right to accept or refuse specific interventions.

📌 Routine, noninvasive activities such as CBT classes, group exercise, or light therapy typically do not require formal informed consent, though the client can still choose to decline participation.

📌 Ensuring informed consent respects autonomy and legal rights, which are crucial in psychiatric care.

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Answer 7

Correct Answers:

"I may be more sensitive to the sun while taking this medication."

Rationale :

🌟 Haloperidol can cause photosensitivity, increasing the risk of sunburns and skin irritation with sun exposure.

🌟 Clients should be advised to use sunscreen, wear protective clothing, and avoid prolonged direct sunlight.

🌟 Recognizing this side effect indicates that the client understands important self-care precautions while on the medication.

🌟 Other listed symptoms, such as tinnitus, urinary incontinence, or metallic taste, are not typical side effects of haloperidol.

🌟 Proper education on side effects enhances medication safety and adherence.

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Answer 8

Correct Answers:

Administer the medication with meals.

Rationale :

📍 Lithium commonly causes gastrointestinal upset (nausea, diarrhea, abdominal discomfort), so administering it with meals or milk helps minimize these effects.

📍 The nurse should also encourage adequate fluid and sodium intake, as lithium levels are affected by sodium and fluid balance, not potassium or glucose levels.

📍 Decreasing potassium or increasing caloric intake is unnecessary unless specifically indicated for other conditions.

📍 Monitoring for lithium toxicity (tremors, confusion, polyuria) is also an essential part of care.

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Answer 9

Correct Answers:

Dual diagnosis treatment

Rationale :

💎 Dual diagnosis treatment is specifically designed for clients who have both a mental health disorder (e.g., antisocial personality disorder) and a substance use disorder (e.g., alcohol dependency).

💎 These programs integrate mental health therapy and substance abuse treatment, addressing both conditions simultaneously for better outcomes.

💎 It provides structured therapy, relapse prevention, and coping strategies tailored to the unique challenges of managing co-occurring disorders.

💎 Codependency support and crisis intervention are not primary treatments for dual disorders, and psychodrama is more useful for exploring emotions rather than treating substance use concurrently with mental illness.

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Answer 10

Correct Answers:

"I spend several hours a day outside gardening when it's sunny."

Rationale :

🌞 Haloperidol decanoate can cause photosensitivity, increasing the risk of sunburns or skin irritation with prolonged sun exposure.

🌞 The nurse should teach the client to limit direct sunlight exposure, wear protective clothing, and use sunscreen while outdoors.

🌞 This statement requires immediate teaching because unprotected sun exposure can lead to serious skin damage in clients taking antipsychotics.

🌞 The other statements reflect positive self-care behaviors: avoiding alcohol (reduces CNS depression), checking blood pressure (monitors for hypotension), and chewing sugar-free gum (relieves dry mouth).

🌞 Addressing photosensitivity risk promotes medication safety and adherence.

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QLexNursing

1 :
A nurse is caring for a client who is receiving treatment for alcohol detoxification. Which of the following medications should the nurse expect to administer during this phase of the client's care?

2 :
A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.)

3 :
A client is becoming increasingly agitated, anxious, and tense. The nurse notes a clenched jaw and a change in the pitch of the client's voice. Which of the following interventions should the nurse implement first?

4 :
A nurse is collecting data from an older adult client who was admitted with heart failure. The nurse should report which of the following findings to the provider as an indication of delirium?

5 :
A nurse is collecting data from a client who has bulimia nervosa. Which of the following findings should the nurse expect?

6 :
A nurse is contributing to the plan of care for a client who has bipolar disorder and whose admission was voluntary. For which of the following interventions should the nurse confirm that the client has given informed consent?

7 :
A nurse is reinforcing teaching about a new prescription for haloperidol with a client who has schizophrenia. Which of the following statements by the client indicates an understanding of the teaching?

8 :
A nurse is contributing to the plan of care for a client who has a new prescription for lithium. Which of the following interventions should the nurse recommend?

9 :
A nurse in a mental health facility is caring for a client who has antisocial personality disorder and alcohol dependency. The nurse should encourage the client to participate in which of the following groups?

10 :
A nurse is reinforcing teaching with a client who started taking haloperidol decanoate 125 mg IM 1 month ago. Which of the following statements by the client should the nurse address?

QLexNursing

1 : A nurse is caring for a client who is receiving treatment for alcohol detoxification. Which of the following medications should the nurse expect to administer during this phase of the client's care?

2 : A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.)

3 : A client is becoming increasingly agitated, anxious, and tense. The nurse notes a clenched jaw and a change in the pitch of the client's voice. Which of the following interventions should the nurse implement first?

4 : A nurse is collecting data from an older adult client who was admitted with heart failure. The nurse should report which of the following findings to the provider as an indication of delirium?

5 : A nurse is collecting data from a client who has bulimia nervosa. Which of the following findings should the nurse expect?

6 : A nurse is contributing to the plan of care for a client who has bipolar disorder and whose admission was voluntary. For which of the following interventions should the nurse confirm that the client has given informed consent?

7 : A nurse is reinforcing teaching about a new prescription for haloperidol with a client who has schizophrenia. Which of the following statements by the client indicates an understanding of the teaching?

8 : A nurse is contributing to the plan of care for a client who has a new prescription for lithium. Which of the following interventions should the nurse recommend?

9 : A nurse in a mental health facility is caring for a client who has antisocial personality disorder and alcohol dependency. The nurse should encourage the client to participate in which of the following groups?

10 : A nurse is reinforcing teaching with a client who started taking haloperidol decanoate 125 mg IM 1 month ago. Which of the following statements by the client should the nurse address?

1 :
A nurse is caring for a client who is receiving treatment for alcohol detoxification. Which of the following medications should the nurse expect to administer during this phase of the client's care?

2 :
A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.)

3 :
A client is becoming increasingly agitated, anxious, and tense. The nurse notes a clenched jaw and a change in the pitch of the client's voice. Which of the following interventions should the nurse implement first?

4 :
A nurse is collecting data from an older adult client who was admitted with heart failure. The nurse should report which of the following findings to the provider as an indication of delirium?

5 :
A nurse is collecting data from a client who has bulimia nervosa. Which of the following findings should the nurse expect?

6 :
A nurse is contributing to the plan of care for a client who has bipolar disorder and whose admission was voluntary. For which of the following interventions should the nurse confirm that the client has given informed consent?

7 :
A nurse is reinforcing teaching about a new prescription for haloperidol with a client who has schizophrenia. Which of the following statements by the client indicates an understanding of the teaching?

8 :
A nurse is contributing to the plan of care for a client who has a new prescription for lithium. Which of the following interventions should the nurse recommend?

9 :
A nurse in a mental health facility is caring for a client who has antisocial personality disorder and alcohol dependency. The nurse should encourage the client to participate in which of the following groups?

10 :
A nurse is reinforcing teaching with a client who started taking haloperidol decanoate 125 mg IM 1 month ago. Which of the following statements by the client should the nurse address?