Question

When doing an admission assessment of a client with a history of alcoholism, the most important factor(s) to assess is/are:

Answer 1

Correct Answers:

when the client last had a drink.

Rationale :

💎 The timing of the last drink is essential to assess the risk for alcohol withdrawal syndrome.

💎 Withdrawal symptoms can begin within 6–12 hours, requiring urgent nursing monitoring.

💎 This information determines when to initiate the CIWA protocol or administer medications.

💎 Delirium tremens and seizures can occur if withdrawal is not promptly addressed.

💎 This is a priority safety concern during admission.

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Answer 2

Correct Answers:

Chiropractic therapy

Rationale :

✏️ Chiropractic therapy involves manual manipulation of the spine to treat subluxations.

✏️ It focuses on aligning the vertebrae to relieve pressure and restore neuromuscular function.

✏️ This therapy is commonly used for back and neck pain.

✏️ It is based on the belief that spinal alignment influences overall health.

✏️ Chiropractors often treat joint and nerve-related complaints.

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Answer 3

Correct Answers:

Orient the client and monitor vital signs

Rationale :

🔴 Post-ECT clients frequently experience temporary confusion or disorientation due to both the treatment and general anesthesia.

🔴 It is essential for the nurse to monitor vital signs immediately to assess for respiratory or cardiovascular instability.

🔴 Orientation helps reestablish a sense of safety, especially as the client may awaken in an unfamiliar setting.

🔴 Close monitoring supports early identification of adverse effects, such as bradycardia, arrhythmias, or postictal agitation.

🔴The nurse must prioritize neurologic and hemodynamic stabilization before progressing to other tasks like fluid intake or ambulation.

🔴 These interventions reflect priority nursing actions during the immediate recovery phase of anesthesia and ECT.

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Answer 4

Correct Answers:

assist the client to identify the trigger situation and choose a coping strategy.

Rationale :

♦️Clients with borderline personality disorder often exhibit impulsivity and emotional reactivity, especially under stress.

♦️ The urge to self-harm is commonly used as a maladaptive method to release or numb intense emotional pain.

♦️ Assisting the client to identify emotional triggers supports self-awareness and early intervention, which are key DBT principles.

♦️ By teaching and reinforcing healthy coping strategies (e.g., journaling, breathing techniques), the nurse helps the client avoid self-destructive choices.

♦️ This approach empowers the client to gain emotional control and develop problem-solving skills over time.

♦️ Providing structure and guidance during distress strengthens the therapeutic relationship and long-term emotional resilience.

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Answer 5

Correct Answers:

"I deserve to be this way."

Rationale :

🖤 This statement reflects internalized guilt, which is a core cognitive distortion in major depressive disorder.

🖤 Depressed individuals often experience excessive self-blame and may perceive their condition as punishment or deserved suffering.

🖤 This belief is concerning because it increases the risk for hopelessness and suicidal ideation.

🖤 Recognizing this negative self-perception helps the nurse tailor cognitive behavioral interventions aimed at reshaping maladaptive thoughts.

🖤 It also provides insight into the severity of the client’s depressive symptoms, which may require both pharmacological and psychotherapeutic support.

🖤 Early identification of such beliefs helps in crisis prevention and improving treatment outcomes.

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Answer 6

Correct Answers:

Pepperoni pizza and red wine

Rationale :

🎯Clients prescribed MAOIs must avoid foods high in tyramine, a naturally occurring compound in aged, fermented, or cured foods.

🎯 Tyramine interacts with MAOIs and can lead to a hypertensive crisis, which is a potentially fatal medical emergency.

🎯Pepperoni and red wine are classic examples of high-tyramine foods and must be excluded from the diet.

🎯 Symptoms of a hypertensive crisis include sudden headache, neck stiffness, nausea, chest pain, and elevated blood pressure.

🎯 The nurse must provide clear, written dietary guidance, and reinforce this teaching regularly to prevent accidental ingestion.

🎯 Monitoring for adherence is also essential, especially during the early weeks of treatment initiation.

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Answer 7

Correct Answers:

Disorganized thinking and the inability to remain seated.

Rationale :

🌀This reflects a classic manic presentation in bipolar I disorder, characterized by racing thoughts, distractibility, and pressured speech.

🌀 Clients often exhibit excessive psychomotor activity, moving from task to task without completing any due to poor focus.

🌀 The inability to remain seated, paired with flight of ideas, can escalate into risky or aggressive behavior.

🌀 Manic states are also associated with reduced need for sleep, impulsive spending, and poor nutritional intake, as described in the scenario.

🌀 Immediate assessment and intervention are crucial to ensure client safety and prevent exhaustion or harm.

🌀Nurses must use structured environments and mood stabilizers to help manage the manic episode.

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Answer 8

Correct Answers:

Encourage dividing tasks into smaller, attainable steps and reward successful completion.

Rationale :

🧩 Clients with ADHD struggle with sustained attention, especially in unstructured environments like the inpatient setting.

🧩 Dividing tasks helps prevent overwhelm and frustration, making academic and daily tasks more manageable.

🧩 Using positive reinforcement, such as verbal praise or tokens, helps motivate clients and strengthens behavior.

🧩 This intervention encourages goal setting, time management, and builds self-confidence through achievable success.

🧩 It aligns with evidence-based behavioral therapy strategies used to support adolescents with ADHD.

🧩 Consistent structure and expectations help the client learn how to self-regulate and succeed in future academic or social settings.

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Answer 9

Correct Answers:

Little tolerance for being alone

Rationale :

⏺️ Clients with borderline personality disorder often experience an intense fear of abandonment, even in minor separations.

⏺️ They may desperately seek companionship or react with panic, rage, or desperation when left alone.

⏺️ This stems from attachment insecurity and identity disturbance, hallmark traits of BPD.

⏺️ The behavior can manifest as clinging, frequent crises, or threats of self-harm to avoid separation.

⏺️ Addressing this requires consistent boundaries, validation, and teaching clients to tolerate being alone without panic.

⏺️ Interventions like DBT aim to help clients regulate these intense fears and improve interpersonal functioning.

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Answer 10

Correct Answers:

Being raised by multiple caregivers

Rationale :

🟣Early childhood development is highly dependent on stable, consistent caregiver relationships.

🟣 Being raised by multiple caregivers may disrupt the formation of secure attachment bonds, leading to emotional dysregulation.

🟣 This instability increases the risk for later development of behavioral issues, anxiety, or mood disorders.

🟣 Children in such environments may exhibit trust issues, poor self-esteem, or difficulty forming relationships.

🟣 Assessing caregiver consistency is a critical part of the psychosocial history in pediatric mental health evaluations.

🟣 Identifying early instability allows for early intervention and therapeutic support to mitigate future psychiatric concerns.

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QLexNursing

1 :
When doing an admission assessment of a client with a history of alcoholism, the most important factor(s) to assess is/are:

2 :
The nurse understands that when a practitioner corrects subluxation by manipulating the vertebrae of the spinal column, the practitioner is employing which therapy?

3 :
A client has just been admitted to the Post Anesthesia Care Unit after electroconvulsive therapy (ECT). Which intervention will the nurse perform first?

4 :
A client with borderline personality disorder reported to the nurse in the clinic that they feel empty and anxious and wants to cut their arms. The nurse should:

5 :
During assessment, the nurse is most likely to find the attitude of the depressed client toward his illness to be:

6 :
A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. When teaching the client about the effects of tyramine, which foods will the nurse caution the client to avoid?

7 :
A family describes a client diagnosed with bipolar disorder as being "on the move." The client sleeps 3-4 hours nightly, spends excessively, and has recently lost 10 pounds. During the initial client assessment, which response would the nurse expect?

8 :
An adolescent diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) is having difficulty maintaining concentration in the inpatient milieu. Which nursing intervention would help improve the client's task performance?

9 :
In assessing a client diagnosed with borderline personality disorder, which characteristic would the nurse expect to observe?

10 :
Which predisposing factor obtained during the nursing assessment would cause the nurse to consider a child to be at risk for the development of a psychiatric disorder?

QLexNursing

1 : When doing an admission assessment of a client with a history of alcoholism, the most important factor(s) to assess is/are:

2 : The nurse understands that when a practitioner corrects subluxation by manipulating the vertebrae of the spinal column, the practitioner is employing which therapy?

3 : A client has just been admitted to the Post Anesthesia Care Unit after electroconvulsive therapy (ECT). Which intervention will the nurse perform first?

4 : A client with borderline personality disorder reported to the nurse in the clinic that they feel empty and anxious and wants to cut their arms. The nurse should:

5 : During assessment, the nurse is most likely to find the attitude of the depressed client toward his illness to be:

6 : A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. When teaching the client about the effects of tyramine, which foods will the nurse caution the client to avoid?

7 : A family describes a client diagnosed with bipolar disorder as being "on the move." The client sleeps 3-4 hours nightly, spends excessively, and has recently lost 10 pounds. During the initial client assessment, which response would the nurse expect?

8 : An adolescent diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) is having difficulty maintaining concentration in the inpatient milieu. Which nursing intervention would help improve the client's task performance?

9 : In assessing a client diagnosed with borderline personality disorder, which characteristic would the nurse expect to observe?

10 : Which predisposing factor obtained during the nursing assessment would cause the nurse to consider a child to be at risk for the development of a psychiatric disorder?

1 :
When doing an admission assessment of a client with a history of alcoholism, the most important factor(s) to assess is/are:

2 :
The nurse understands that when a practitioner corrects subluxation by manipulating the vertebrae of the spinal column, the practitioner is employing which therapy?

3 :
A client has just been admitted to the Post Anesthesia Care Unit after electroconvulsive therapy (ECT). Which intervention will the nurse perform first?

4 :
A client with borderline personality disorder reported to the nurse in the clinic that they feel empty and anxious and wants to cut their arms. The nurse should:

5 :
During assessment, the nurse is most likely to find the attitude of the depressed client toward his illness to be:

6 :
A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. When teaching the client about the effects of tyramine, which foods will the nurse caution the client to avoid?

7 :
A family describes a client diagnosed with bipolar disorder as being "on the move." The client sleeps 3-4 hours nightly, spends excessively, and has recently lost 10 pounds. During the initial client assessment, which response would the nurse expect?

8 :
An adolescent diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) is having difficulty maintaining concentration in the inpatient milieu. Which nursing intervention would help improve the client's task performance?

9 :
In assessing a client diagnosed with borderline personality disorder, which characteristic would the nurse expect to observe?

10 :
Which predisposing factor obtained during the nursing assessment would cause the nurse to consider a child to be at risk for the development of a psychiatric disorder?