A nurse is caring for a client in the emergency department (ED).

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Alcohol withdrawal syndrome refers to the collection of symptoms that occur when individuals who are dependent on alcohol abruptly reduce or stop their alcohol intake.

Benzodiazepines, such as diazepam or lorazepam, are commonly used to manage symptoms such as anxiety, tremors, and seizures.

Providing a safe environment also ensures that the client does not involve in self-harming activities due to hallucinations.

Alcohol withdrawal syndrome is associated with an increased risk of seizures, particularly within the first 48 hours after cessation of alcohol consumption. Seizures can range from mild to severe and may be life-threatening if not promptly managed.

Chronic alcohol abuse can lead to dehydration and electrolyte imbalances due to increased urinary output, decreased fluid intake, and poor nutrition. Additionally, alcohol withdrawal itself can exacerbate fluid and electrolyte disturbances due to vomiting, diarrhea, diaphoresis, and increased metabolic demand.

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Correct Answer is C

Explanation

C. A neutral attitude communicates respect, professionalism, and non-threatening intentions. It helps to minimize the client's feelings of being scrutinized or manipulated and creates a safe environment for the client to engage in therapeutic interactions.

A. Disclosing personal information may further exacerbate the client's mistrust and suspicion, as they may interpret it as confirmation of their paranoid beliefs or as an attempt to manipulate them.

B. Approaching the client frequently throughout the day may be overwhelming and increase the client's suspicion. Clients with paranoid personality disorder often feel threatened by perceived intrusions into their personal space or privacy.

D. While it's essential to respect the client's autonomy and boundaries, waiting for the client to initiate interaction may prolong the establishment of a therapeutic relationship, especially with a client who is suspicious and mistrustful.

A. Talk to the client and identify the specific limits that are required of the client's behavior. B. Escort the client to her room each time the nurse observes the client socializing with other clients. C. Discuss the problem in a community meeting with the other clients on the unit present. D. Tell the other clients to ignore the client's lies.

Correct Answer is A

Explanation

A. Engaging in a conversation with the client allows the nurse to set clear expectations and boundaries. The nurse can explain the acceptable behavior and the consequences of disruptive actions. It’s essential to approach this conversation calmly and professionally.

B. While removing the client from social situations may temporarily prevent disruptive behavior, it does not address the underlying issue. Isolating the client may also negatively impact their well- being. It’s better to address the behavior directly rather than resorting to isolation.

C. Holding a community meeting involving all clients may not be appropriate or effective. It could escalate tensions and create an uncomfortable environment for everyone. Individualized interventions are more effective.

D. Ignoring disruptive behavior may not be the best approach. It’s essential to address the issue directly rather than expecting other clients to tolerate disruptive behavior.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with paranoid personality disorder who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?

Correct Answer is C

Explanation

A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain to the nursing staff about the client's disruptive behaviors. Which of the following initial actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse. "I should have died because I am totally worthless." Which of the following responses should the nurse make?

A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?

A client with borderline personality disorder says to the nurse, "I feel so comfortable talking with you. You seem to have a special way about you that really helps me." Which would be the most appropriate response by the nurse?

A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following characteristics are expected findings of OCD? (Select all that apply.)

A client experiences panic attacks when confronted with riding in elevators. The therapist is teaching the client ways to relax while incrementally exposing the client to getting on an elevator. This technique is called which of the following?

A home-health nurse is assessing a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to accomplish which of the following?

A client is seeking treatment for a specific phobia. The nurse in the anxiety disorders clinic documents that the client's anxiety is related to exposure to the phobic object. Which is a realistic outcome for anxiety self-control in this situation?