A nurse in an addiction rehabilitation center is contributing to the plan of care for a newly admitted client who has an alcohol use disorder. Which of the following interventions is the nurse's priority?

Place the client in a private room.

Determine the client's level of disorientation.

Pad the side rails of the bed with towels.

Accompany the client when ambulating.

Answer and Explanation

The Correct Answer is D

Accompany the client when ambulating. The nurse’s priority when caring for a client with alcohol use disorder and who is experiencing withdrawal symptoms is to prevent harm to the client. Physiologic manifestations of alcohol withdrawal syndrome include seizures, delirium tremens (DTs), and hallucinations. Therefore, ensuring the client’s safety is of the utmost importance. Accompanying the client when ambulating is the priority intervention as alcohol withdrawal may lead to ataxia, weakness, and dizziness which may lead to falls.

Choice A, placing the client in a private room, does not address the client’s physical needs.

Choice B, determining the client's level of disorientation, is something necessary to assess but not the priority.

Choice C, padding the side rails of the bed with towels, is not the priority intervention, and contributes little to the prevention of falls.

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Correct Answer is B

Explanation

In clients with obsessive-compulsive disorder (OCD), cleaning and organizing can be a way of decreasing anxiety to a tolerable level. This behavior is a compulsive behavior that is often related to the individual's obsessions. It is not an attempt to manipulate or control others, limit interaction with others, or focus attention on useful tasks.

A. The client imagines being in a quiet, relaxing environment. B. The client trains his mind to relax by using deep inner resources. C. The client learns to change negative thoughts into positive statements. D. The client learns the source of his stress by writing down daily events.

Correct Answer is C

Explanation

"The client learns to change negative thoughts into positive statements." This demonstrates the effective use of cognitive reframing, which involves changing negative thoughts into positive self-talk. This strategy can help to reduce stress and improve coping skills.

Choice A, "The client imagines being in a quiet, relaxing environment," is not an example of cognitive reframing, but rather an example of visualization, which can also be useful in reducing stress.

Choice B, "The client trains his mind to relax by using deep inner resources," is not an example of cognitive reframing, but rather an example of relaxation training.

Choice D, "The client learns the source of his stress by writing down daily events," is not an example of cognitive reframing, but rather an example of stress management through self-reflection.

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A nurse in an addiction rehabilitation center is contributing to the plan of care for a newly admitted client who has an alcohol use disorder. Which of the following interventions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has obsessive-compulsive disorder (OCD) and is constantly picking up after others and cleaning in the day room. The nurse should recognize the client's actions as which of the following?

Correct Answer is B

Explanation

A nurse is helping a client relieve stress through cognitive reframing. Which of the following actions by the client demonstrates effective use of cognitive reframing?

Correct Answer is C

Explanation

A nurse is assisting with the admission of a client to an acute mental health unit following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions should the nurse take first?

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

A nurse is caring for a client with whom he has developed a therapeutic relationship and who will be discharged later in the day. The client thanks the nurse for his help during the hospitalization. Which of the following responses should the nurse make?

A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

Which statement by the client indicates an understanding of the information provided about sertraline?

A nurse is caring for a client who has anorexia nervosa and insists on exercising three times each day. Which of the following actions should the nurse take?

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