Question

A nurse in an acute care facility is planning care for a client who has a history of alcohol use disorder and is admitted while intoxicated. Which of the following interventions should the nurse plan for the client?

Answer 1

Correct Answers:

Implement seizure precautions.

Rationale :

✏️ A client with alcohol use disorder who is admitted while intoxicated is at risk for developing alcohol withdrawal as the blood alcohol level decreases.

✏️ Withdrawal seizures are a serious complication that can occur after abrupt reduction or cessation of prolonged alcohol consumption.

✏️ The nurse should therefore implement seizure precautions proactively to protect the client from injury.

✏️ Precautions can include maintaining a safe environment, having appropriate emergency equipment available, and closely monitoring the client.

✏️ Alcohol withdrawal can progress from tremors, anxiety, diaphoresis, and agitation to seizures and severe withdrawal manifestations.

✏️ Severe withdrawal can also progress to delirium tremens, which can involve confusion, hallucinations, autonomic hyperactivity, and significant cardiovascular instability.

✏️ Frequent assessment for emerging withdrawal symptoms is essential because manifestations can worsen as alcohol is metabolized.

✏️ Therefore, implementing seizure precautions is an appropriate planned intervention for this hospitalized client.

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Answer 2

Correct Answers:

The client's best friend moved away.

Rationale :

✨ The loss of regular contact with a best friend can create significant emotional and psychosocial stress for a client recovering from major surgery.

✨ Recovery from coronary artery bypass graft (CABG) surgery requires adequate physical rest as well as emotional support.

✨ A close friend can be an important part of the client’s social support system during recovery.

✨ Having the friend move away can contribute to feelings of loss, loneliness, sadness, or anxiety.

✨ Increased psychological stress can interfere with the client’s ability to follow the recovery plan and maintain healthy behaviors.

✨ Stress can also activate the sympathetic nervous system, increasing heart rate and blood pressure and placing additional demands on the cardiovascular system.

✨ Adequate social support and effective coping strategies are important components of recovery following cardiac surgery.

✨ Therefore, the client’s best friend moving away represents a stressor that might interfere with recovery.

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Answer 3

Correct Answers:

The client is able to follow commands.

Rationale :

✳️ Physical restraints should be discontinued as soon as the behavior that required their use is no longer present.

✳️ A client who can follow commands demonstrates sufficient behavioral control to respond appropriately to staff directions.

✳️ Following commands indicates that less restrictive measures can potentially maintain the client’s safety.

✳️ Restraints should never be continued simply for convenience, punishment, or coercion.

✳️ The nurse should continually reassess whether the client still presents an immediate risk of injury to self or others.

✳️ Once the client demonstrates safe behavior and can follow directions, the principle of using the least restrictive intervention supports removing the restraints.

✳️ After removal, the nurse should continue monitoring the client and use alternatives such as verbal redirection, environmental modification, and close observation when appropriate.

✳️ Therefore, the client’s ability to follow commands is the best indication that physical restraints can be removed.

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Answer 4

Correct Answers:

Position the mattress on the floor.
Install sensor devices on outside doors.
Put locks at top of doors.

Rationale :

✅ Position the mattress on the floor

💎 An older adult with Alzheimer’s disease who wanders and has a history of falls requires interventions that reduce the risk of injury.

💎 Placing the mattress on the floor minimizes the distance the client could fall when getting out of bed.

💎 Alzheimer’s disease can cause confusion, impaired judgment, and disorientation, especially during nighttime hours.

💎 A standard elevated bed can increase the severity of injury if the client attempts to get up independently and falls.

💎 A low sleeping surface is a least-restrictive environmental safety measure that does not prevent the client from moving freely.

💎 The surrounding floor area should also remain clear of obstacles and hazards.

💎 This intervention is especially appropriate because the client already has a history of falls.

💎 Therefore, positioning the mattress on the floor helps reduce fall-related injury.

✅ Install sensor devices on outside doors

💎 Door sensors or alarms alert the caregiver when the client attempts to leave the home.

💎 Clients with Alzheimer’s disease can wander because of confusion, restlessness, or inability to recognize their surroundings.

💎 Wandering outside can expose the client to traffic, extreme temperatures, getting lost, and falls.

💎 A sensor provides an early warning without physically restraining the client.

💎 The caregiver can respond promptly when the alarm indicates that an outside door has been opened.

💎 Environmental modifications are important components of maintaining home safety for clients with dementia.

💎 Sensors are particularly valuable at night, when the caregiver may not immediately notice wandering.

💎 Therefore, installing sensor devices on outside doors is an appropriate safety intervention.

✅ Put locks at top of doors

💎 Placing door locks high on outside doors can decrease the likelihood that a cognitively impaired client will leave the home unnoticed.

💎 Clients with Alzheimer’s disease may have difficulty recognizing unsafe situations because of impaired judgment.

💎 A lock positioned outside the client’s usual line of sight can help prevent unsupervised wandering.

💎 Preventing nighttime wandering outside reduces the risk of falls, getting lost, and environmental exposure.

💎 This environmental modification allows the caregiver to improve safety without routinely using physical restraints.

💎 Caregivers should continue providing appropriate supervision because locks alone cannot eliminate wandering risk.

💎 Safe exit strategies should also account for emergency evacuation and fire safety requirements.

💎 Therefore, placing locks at the top of doors is appropriate for this client.

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Answer 5

Correct Answers:

Document the client's refusal of the treatment in the medical record.

Rationale :

⚽ Involuntary commitment does not automatically eliminate a client’s right to participate in decisions regarding medical and psychiatric treatment.

⚽ Electroconvulsive therapy (ECT) generally requires informed consent before treatment is administered, except under specific legal provisions or emergencies governed by applicable law.

⚽ A competent client retains the right to refuse treatment, even when hospitalized involuntarily.

⚽ The nurse should respect the client’s autonomy and should not attempt to force or coerce acceptance of ECT.

⚽ The client is also not required to provide the nurse with a reason before the refusal can be acknowledged and documented.

⚽ The nurse should accurately document the client’s refusal and communicate it to the appropriate members of the healthcare team.

⚽ Proper documentation provides a record that the client exercised the right to refuse treatment and allows the team to determine appropriate next steps.

⚽ Therefore, documenting the client’s refusal in the medical record is the appropriate nursing action.

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Answer 6

Correct Answers:

A client who has bipolar disorder and is exhibiting poor impulse control

Rationale :

🎯 A client with bipolar disorder who demonstrates poor impulse control has an increased risk for behaviors that can compromise personal or environmental safety.

🎯 During a manic episode, impaired judgment and impulsivity can cause the client to act without considering consequences.

🎯 The client may engage in reckless spending, unsafe sexual behavior, aggression, substance use, or other high-risk activities.

🎯 Poor impulse control can also result in rapid escalation from an idea or emotion to an unsafe action.

🎯 The nurse should reassess the client’s current behavior and update the plan of care with appropriate safety interventions and limit setting.

🎯 Providing a low-stimulation environment, establishing clear limits, and closely monitoring escalating behavior can help reduce risk.

🎯 Safety concerns take priority over manifestations that are expected features of a disorder but do not indicate an immediate risk of harm.

🎯 Therefore, the client with bipolar disorder and poor impulse control requires an updated plan of care to ensure safety.

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Answer 7

Correct Answers:

Allow the client unlimited time for the grieving process.

Rationale :

🧿 Receiving a terminal cancer diagnosis can trigger an intense grieving process involving emotional, psychological, social, and spiritual responses.

🧿 The nurse should provide the client with time and emotional support to process the diagnosis at the client’s own pace.

🧿 Grieving is an individualized process, and there is no predetermined amount of time in which a person must complete it.

🧿 The client may experience emotions such as denial, anger, fear, sadness, bargaining, or acceptance during adjustment to the diagnosis.

🧿 Therapeutic nursing care includes being present, listening actively, and allowing expression of feelings without judgment.

🧿 The nurse should avoid rushing the client toward acceptance or suggesting that particular emotional responses are inappropriate.

🧿 Allowing sufficient time supports the client’s coping and emotional adjustment while preserving dignity and autonomy.

🧿 Therefore, allowing the client unlimited time for the grieving process is the most therapeutic action listed.

❌ Offer the client advice about various treatment choices.

🧿 Giving personal advice can interfere with the client’s autonomy and independent decision-making.

❌ Discourage the client from forming new relationships.

🧿 Discouraging relationships could increase loneliness and emotional distress.

❌ Change the subject when the client becomes upset.

🧿 Therapeutic communication involves acknowledging emotions and remaining present and supportive.

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Answer 8

Correct Answers:

10

Rationale :

🧮 Calculation

🍊 Prescription: 40 mg/day divided into 2 doses

🍊 Available: 10 mg/5 mL

➤ Step 1: Determine the dose in mg

40 mg ÷ 2 doses = 20 mg per dose

➤ Step 2: Calculate the volume

10 mg = 5 mL

20 mg = x mL

x=20 mg×5 mL÷ 10 mgx

20 × 5 ÷ 10 = 10 mL

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Answer 9

Correct Answers:

Identify prior coping skills.

Rationale :

🌸 The first step in crisis intervention is assessment, which includes identifying how clients have successfully coped with stressful situations in the past.

🌸 Determining prior coping skills helps the nurse assess the adolescents’ existing strengths and ability to manage the current crisis.

🌸 Witnessing a classmate’s suicide is a traumatic event that can overwhelm usual coping mechanisms and create significant emotional distress.

🌸 The nurse should assess which coping strategies were previously effective, healthy, and available to each adolescent.

🌸 Previous successful coping strategies can often be strengthened and applied to the current crisis.

🌸 This assessment also helps identify adolescents who have ineffective coping mechanisms and may require more intensive intervention.

🌸 Once coping abilities and immediate needs have been assessed, the nurse can develop appropriate interventions and connect clients with additional support and resources.

🌸 Therefore, identifying prior coping skills should occur before initiating referrals or reviewing community resources.

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Answer 10

Correct Answers:

"You might experience confusion fer a few hours after treatment."

Rationale :

🌻 Electroconvulsive therapy (ECT) is an effective treatment for severe major depressive disorder, particularly when rapid improvement is needed or other treatments have been ineffective.

🌻 Temporary confusion and disorientation can occur immediately after ECT and may persist for several hours following treatment.

🌻 Clients can also experience short-term memory impairment, particularly surrounding events occurring near the treatment period.

🌻 Other common temporary adverse effects include headache, muscle soreness, and nausea after the procedure.

🌻 The client is monitored closely during recovery until orientation, vital signs, and protective reflexes are adequately restored.

🌻 Teaching the client about expected temporary confusion helps reduce anxiety and prepares the client for the recovery period.

🌻 Cognitive effects usually improve following treatment, although some clients can experience more persistent memory difficulties.

🌻 Therefore, informing the client that confusion can occur for several hours after ECT is appropriate teaching.

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QLexNursing

1 :
A nurse in an acute care facility is planning care for a client who has a history of alcohol use disorder and is admitted while intoxicated. Which of the following interventions should the nurse plan for the client?

2 :
A home health nurse is visiting a client who is recovering from coronary artery bypass surgery and reports experiencing stress. The nurse should determine that which of the following factors might interfere with the client's recovery?

3 :
A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?

5 :
A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take?

6 :
A nurse in a mental health facility is caring for a group of clients. After assessing the clients, which of the following clients requires an update to their plan of care to ensure client safety?

7 :
A nurse is caring for a client who has just received a terminal cancer diagnosis from his provider. Which of the following actions should the nurse take?

❌ Offer the client advice about various treatment choices.

❌ Discourage the client from forming new relationships.

❌ Change the subject when the client becomes upset.

🧮 Calculation

9 :
A nurse is leading a crisis intervention group for adolescents who witnessed the suicide of a classmate. Which of the following actions should the nurse take first?

10 :
A nurse is teaching a client who has major depressive disorder about electroconvulsive therapy. Which of the following information should the nurse include?

QLexNursing

1 : A nurse in an acute care facility is planning care for a client who has a history of alcohol use disorder and is admitted while intoxicated. Which of the following interventions should the nurse plan for the client?

2 : A home health nurse is visiting a client who is recovering from coronary artery bypass surgery and reports experiencing stress. The nurse should determine that which of the following factors might interfere with the client's recovery?

3 : A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?

5 : A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take?

6 : A nurse in a mental health facility is caring for a group of clients. After assessing the clients, which of the following clients requires an update to their plan of care to ensure client safety?

7 : A nurse is caring for a client who has just received a terminal cancer diagnosis from his provider. Which of the following actions should the nurse take?

❌ Offer the client advice about various treatment choices.

❌ Discourage the client from forming new relationships.

❌ Change the subject when the client becomes upset.

🧮 Calculation

9 : A nurse is leading a crisis intervention group for adolescents who witnessed the suicide of a classmate. Which of the following actions should the nurse take first?

10 : A nurse is teaching a client who has major depressive disorder about electroconvulsive therapy. Which of the following information should the nurse include?

1 :
A nurse in an acute care facility is planning care for a client who has a history of alcohol use disorder and is admitted while intoxicated. Which of the following interventions should the nurse plan for the client?

2 :
A home health nurse is visiting a client who is recovering from coronary artery bypass surgery and reports experiencing stress. The nurse should determine that which of the following factors might interfere with the client's recovery?

3 :
A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?

5 :
A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take?

6 :
A nurse in a mental health facility is caring for a group of clients. After assessing the clients, which of the following clients requires an update to their plan of care to ensure client safety?

7 :
A nurse is caring for a client who has just received a terminal cancer diagnosis from his provider. Which of the following actions should the nurse take?

9 :
A nurse is leading a crisis intervention group for adolescents who witnessed the suicide of a classmate. Which of the following actions should the nurse take first?

10 :
A nurse is teaching a client who has major depressive disorder about electroconvulsive therapy. Which of the following information should the nurse include?