A female client is admitted with abdominal pain, possibly due to a gastric ulcer. Two days after admission, the client reports feeling nervous and tremulous. Further assessment reveals that the client's family is bringing a gin and tonic each night to help her relax. Which action(s) should the nurse take? Select all that apply.

Ask the client if she has any alcohol in the room at this time.

Administer an PRN prescription for an antianxiety drug.

Inform the family that they are enabling the client.

Observe for signs to determine if client is inebriated.

Schedule a conference with the client and family members.

Answer and Explanation

Correct Answer : A,D,E

A. Ask the client if she has any alcohol in the room at this time: This is an essential step in assessing for immediate safety and contraband that may impact her treatment plan, especially considering her symptoms and possible withdrawal risk.

B. Administer a PRN prescription for an antianxiety drug: This could mask symptoms of alcohol withdrawal or interact negatively with alcohol. Medication should be given only after thorough assessment and consultation.

C. Inform the family that they are enabling the client: While family education is important, using accusatory language like "enabling" can damage therapeutic relationships. A nonjudgmental, supportive approach is better.

D. Observe for signs to determine if client is inebriated: Monitoring for inebriation supports accurate clinical assessment and decisions about withdrawal protocols, safety, and medication timing.

E. Schedule a conference with the client and family members: A joint meeting allows open discussion, identifies care goals, and promotes understanding and support from all parties involved.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Recommend that the client avoid driving over the bridge: Avoidance reinforces the anxiety and prevents the client from developing effective coping mechanisms. Over time, this may worsen the phobia and reduce the client’s functional independence and quality of life.

B. Teach the client to listen to music or audio books while driving: Calming distractions can help reduce anxiety symptoms and promote gradual exposure to the feared situation. This approach supports desensitization while helping the client stay in control and manage symptoms.

C. Tell the client to drive over the bridge until fear is manageable: Flooding, or forced prolonged exposure, may overwhelm the client and worsen anxiety. A more gradual, supportive approach is generally safer and more effective in treating specific and anxiety.

D. Encourage the client to have the spouse drive in stressful places: Delegating driving to someone else may provide short-term relief, but it limits the client’s independence and does not promote long-term coping or resolution of the anxiety trigger.

A. The client reports he was able to sleep through the night B. The client notes continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers. C. The client reports mild nausea and has no desire to eat breakfast D. There is a 1.18 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage E. The left arm is warm to touch. The client's left shoulder and collarbone are symmetric

Correct Answer is ["A","E"]

Explanation

Rationale for Correct Choices:

The nurse assesses the client. The client reports he was able to sleep through the night:
Being able to sleep through the night suggests that the client’s pain is adequately managed, indicating progress in terms of pain control post-surgery or trauma care.
The left arm is warm to touch: The warmth of the left arm indicates that circulation has improved from initially cool to touch. This is a positive sign, as it suggests that there are no significant vascular complications following the fracture or trauma.
The client's left shoulder and collarbone are symmetric: Symmetry of the shoulder and collarbone suggests that there is no new displacement or injury to the bones post-trauma or surgery. This is a good sign indicating that the fracture is properly stabilized.

Rationale for Incorrect Choices:

The client notes continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers: The numbness, tingling, and inability to move his fingers may indicate nerve involvement, which could be a sign of complications such as nerve compression or injury due to the fracture.
The client reports mild nausea and has no desire to eat breakfast: Mild nausea is expected after anesthesia or pain medications, but continued lack of appetite or worsening nausea may signal complications, such as a delayed reaction to anesthesia or a side effect from medication, which should be monitored.
There is a 1.18 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage: While some blood may be expected post-surgery or after trauma, a blood stain of this size should be evaluated for any indication of active bleeding or complications such as hematoma formation. It may not be expected if the bleeding had been controlled.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client returns to the mental health clinic for assistance with an anxiety reaction that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over the bay bridge. Which action in the treatment plan should the nurse implement?

Correct Answer is B

Explanation

Correct Answer is ["A","E"]

Explanation

The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients?

A client reports passing 2 to 3 small, hard stools per week since being placed on a low-residue diet three months ago. Which type of laxative should the nurse expect the healthcare provider to recommend first?

The healthcare provider prescribes the antibiotic cefdinir 300 mg PO every 12 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

The nurse is teaching an older client about the prevention of osteoporosis. Which foods should the nurse recommend to the client to increase in the diet?

The healthcare provider prescribes dalteparin 200 units/kg SUBQ once a day for a client who weighs 154 lb. The medication is available in 25,000 units/mL vial. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

A 3-year-old child is admitted with a Stage II Wilm's tumor. Which preoperative intervention(s) should the nurse implement? Choose all that apply.