During a high school substance abuse class, a student tells the group, “I know that marijuana is not addicting, so why shouldn’t I use it? Which response is best for the nurse to provide?

Marijuana is a highly addictive substance.

Altering one’s ability to think clearly places self and others at risk.

Healthcare providers sometimes prescribe marijuana to control nausea.

Drug use has moral implications that should be discussed with parents.

Answer and Explanation

The Correct Answer is B

A.   While marijuana may not be considered highly addictive compared to some substances, the response should address the potential risks and consequences of marijuana use rather than focusing solely on addiction.
B.   This response highlights the immediate concern of altering one's ability to think clearly, emphasizing potential risks to both the individual and others.
C. Healthcare providers prescribing marijuana for specific medical purposes does not directly address the student's concern about recreational use.
D.   Discussing moral implications may be a subjective approach and may not provide concrete information about the potential risks associated with marijuana use.

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Correct Answer is C

Explanation

A. This question may be perceived as confrontational. It is essential to explore the client's feelings and experiences first.
B. Asking about resignation is premature at this stage. Exploring feelings and experiences is more appropriate initially.
C. This response acknowledges the client's feelings and experiences, allowing for further exploration of the issues that brought him to the clinic.
D. This question is more focused on the client's actions rather than exploring the emotional impact of the events. The nurse should first understand the client's feelings before addressing actions or solutions.

A. Request a team member to assist with seclusion and restraint. B. Administer lorazepam 1.5 mg intramuscularly twice daily as needed. C. Confirm the client’s identity and orientation to time and place. D. Inspect the area for objects that can be used in a dangerous manner. E. None F. None

Correct Answer is D

Explanation

Rationale for A: While seclusion and restraint may be necessary, this should be considered after assessing the environment for immediate safety concerns.

Rationale for B: Administering medication may help calm the client but does not address immediate safety concerns.

Rationale for C: Confirm the client’s identity and orientation to time and place is a therapeutic intervention that helps ground the client during a dissociative episode. However, in a situation where physical aggression is present, ensuring safety takes precedence over reorientation.

Rationale for D. Inspect the area for objects that can be used in a dangerous manner is the first and most critical action. When a client becomes physically aggressive, the nurse's priority is to maintain safety for the client, staff, and others in the environment. Removing or securing potentially harmful objects minimizes the risk of injury and creates a safer setting for subsequent interventions.

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During a high school substance abuse class, a student tells the group, “I know that marijuana is not addicting, so why shouldn’t I use it? Which response is best for the nurse to provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client with post-traumatic stress disorder (PTSD) is experiencing a dissociative disorder episode. The situation quickly escalates, and the client becomes physically aggressive. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. Which action should the nurse implement first?

An older man with a history of multiple falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become increasingly abusive since his release from prison six weeks ago. Which intervention is most important for the nurse to implement?

A client who is experiencing a severe level of anxiety reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?

A client who is an alcoholic receives a prescription for disulfiram 500 mg PO daily. Which instruction should the nurse provide to this client?

An adolescent who is a heroin addict is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?

After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping both feet while pacing the hallway. Which action should the nurse take?

A client diagnosed with schizophrenia has been receiving haloperidol for the past year, and the treatment plan includes moving the client to a lower maintenance dosage. Which intervention should the nurse include in this client’s plan of care? (Select all that apply)