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Administer disulfiram: Disulfiram is used to deter alcohol consumption by causing unpleasant effects when alcohol is consumed. It has no therapeutic use in the treatment of gambling disorders and would not address the behavioral or psychological components involved.

Encourage participation in exposure therapy: Exposure therapy is typically used for anxiety disorders, such as phobias or post-traumatic stress disorder. It is not a standard treatment for gambling disorder, which requires cognitive and behavioral interventions tailored to impulse control.

Administer memantine: Memantine is primarily used to manage symptoms of Alzheimer’s disease and is not an approved or evidence-based treatment for gambling disorder. Its mechanism of action is unrelated to the neurobiology of behavioral addictions like gambling.

"This surgery can cause an increase in the amount of semen.": A transurethral resection of the prostate (TURP) often results in retrograde ejaculation, meaning semen may flow backward into the bladder. The volume of visible semen typically decreases, not increases, due to this common complication.

“I will not be able to have sexual intercourse after this surgery.": TURP does not prevent sexual intercourse. While temporary issues like erectile dysfunction or retrograde ejaculation may occur, most clients can resume sexual activity after recovery. This belief represents a misunderstanding of surgical outcomes.

“This surgery will prevent me from being able to have an erection.": Although some men may experience temporary erectile dysfunction postoperatively, TURP typically does not cause permanent loss of erectile function. Misconceptions about impotence should be addressed through accurate education.

Seeking clarification: Seeking clarification involves asking the client to explain something they have already said to ensure mutual understanding. It usually occurs in response to ambiguous or unclear statements, not as an initial, open-ended invitation to speak.

Reflecting: Reflecting is a technique in which the nurse restates the client’s feelings or thoughts to encourage deeper exploration. The nurse in this case is not restating anything but is instead prompting the client to share independently.

Focusing: Focusing involves guiding the conversation toward a specific topic or detail the client has already brought up. Since the nurse is initiating a broad and open-ended question, focusing is not the technique being used here.

Explore the client's desired goals: Exploring future goals is tertiary prevention, which aims at restoring function and promoting long-term adaptation after a life event. While important, it does not address immediate detection or intervention needs during an acute phase.

Discuss available support systems with the client: This is a supportive and therapeutic action, but it is part of tertiary prevention, which promotes recovery and prevents further decline. It is not as immediate or diagnostic as evaluating current coping abilities.

Ensure the safety of the client: Ensuring client safety is always a priority if there is any indication of harm or suicidal ideation. However, if no imminent safety risk is present, it does not serve as the main focus of secondary prevention, which emphasizes early detection and screening.

Librium: Librium (chlordiazepoxide) is a benzodiazepine used primarily during alcohol withdrawal to manage symptoms such as anxiety, tremors, or seizures. It is not used for long-term relapse prevention due to the risk of dependence and lack of deterrent effect on alcohol use.

Clonidine: Clonidine is an antihypertensive agent that can help reduce autonomic symptoms during acute alcohol or opioid withdrawal. However, it does not play a role in preventing relapse or deterring future alcohol use.

Phenobarbital: Phenobarbital, a barbiturate, may be used in certain alcohol withdrawal protocols for seizure control or severe withdrawal symptoms. However, it is not used for relapse prevention and carries a high potential for dependence and sedation.

Place a waterproof pad under the client's buttocks: This action addresses the symptom of leakage rather than identifying or correcting the cause. While it may help manage moisture, it does not ensure the catheter is functioning properly or prevent further complications.

Clip the drainage tubing to the edge of the mattress: Clipping the tubing can obstruct flow and increase the risk of urine retention or reflux. Tubing should be secured loosely and not kinked, with no tension that might disrupt drainage or lead to malfunction.

Position the drainage bag below the level of the client's bladder: While proper bag positioning is important to promote gravity drainage, it does not specifically verify safe functioning if leakage is occurring. Ensuring the drainage system is intact is the first step in evaluating catheter function.

Assist the client with dangling off the side of the bed: Early ambulation is important in the postoperative period to prevent complications such as atelectasis or deep vein thrombosis. However, it is not the first action when an elevated temperature is observed, as the cause of the fever must be assessed first.

Instruct the client to breathe deeply and cough: Encouraging deep breathing and coughing promotes lung expansion and reduces the risk of atelectasis and pneumonia, other causes of postoperative fever. While beneficial, checking the incision for infection is a more direct and immediate assessment for a common and serious cause of postoperative fever.

Obtain a prescription to check the client's CBC: A CBC can provide useful information on infection or inflammation, but obtaining lab orders should come after performing a focused assessment to gather immediate, observable data that may warrant urgent action.

Assist the client with developing a safety plan: While crucial for long-term well-being, safety planning should come after assessing the current situation. The nurse must first understand the context of the incident to tailor the plan effectively and ensure it aligns with the client’s readiness and safety.

Provide the client with information about local shelters: Offering shelter information is supportive and may be part of discharge or follow-up teaching. However, this should follow the initial assessment, as the client may not yet be ready to consider leaving or may have specific needs not met by general resources.

Refer the client to a support group: Support groups are helpful for emotional healing and connection but are not an immediate priority. Without understanding the client’s current circumstances, risk level, and readiness to engage, such a referral may not be appropriate at this stage.

Ask the charge nurse to explain the purpose of the medication: While consulting experienced colleagues is acceptable, relying solely on another person without verifying the medication through a formal, credible source may lead to misinformation. Independent verification is a safer and more accountable approach.

Ask the client to state the indication for the medication: Clients may not always have accurate knowledge of their medications or may misunderstand the reason for their use. Relying on client input does not ensure medication safety and is not a substitute for clinical validation.

Allow the client to self-administer the prepared medication: Allowing a client to self-administer a medication that the nurse does not understand is unsafe and violates standards of medication administration. Nurses are responsible for knowing what they administer and ensuring it is appropriate for the client's condition.

"Rest in supine position for 30 minutes after a meal.": Lying flat after a meal increases the risk of aspiration particularly in stroke clients who may have impaired swallowing. A more upright position should be encouraged during and after meals to reduce this risk.

"Use the arm on your affected side to brush your hair.": Stroke often leads to muscle weakness or paralysis on one side, making it difficult or unsafe to perform tasks with the affected limb. Initially, clients should use their stronger arm while the affected side is supported and rehabilitated gradually.

"Use a straw when you drink liquids.": Using a straw can increase the risk of aspiration in clients with post-stroke dysphagia by promoting rapid fluid intake. It is generally contraindicated until a swallowing assessment confirms that it is safe.

Paranoid personality disorder: This disorder is marked by distrust and suspicion of others, but it is not closely associated with the development of anorexia nervosa. It does not typically involve the rigid control over food and body image seen in eating disorders.

Schizotypal personality disorder: While schizotypal personality disorder involves social anxiety and eccentric behaviors, it is more aligned with psychotic spectrum disorders than with the rigid and perfectionistic traits commonly seen in anorexia nervosa.

History of attention deficit hyperactivity disorder: ADHD may be more associated with impulsive eating behaviors and a higher risk for binge eating or bulimia nervosa, rather than the restrictive and perfectionistic traits seen in anorexia nervosa.

"My anxiety has been getting a little easier to deal with every day.": Naltrexone is not primarily used to treat anxiety. While improvement in anxiety may occur secondarily as alcohol use decreases, this statement does not directly reflect the intended therapeutic effect of naltrexone in substance use treatment.

"When I had one drink last week. I had extreme nausea and vomited several times.": This describes the effect of disulfiram, not naltrexone. Disulfiram causes an aversive reaction to alcohol, while naltrexone does not produce sickness when alcohol is consumed; it simply reduces the reward response.

“Since I quit drinking. I have not had any hallucinations.": Hallucinations are associated with alcohol withdrawal, not the effect of naltrexone. Naltrexone does not prevent withdrawal symptoms or hallucinations; it is used after detox to help maintain abstinence and reduce relapse.

A client who has narcissistic personality disorder and refuses to be alone in their room: Clients with narcissistic personality disorder typically display a need for admiration and may fear abandonment, but they are not at increased risk for physical injury.

A client who has social anxiety disorder and refuses to attend group therapy: Avoidance of social settings is a hallmark of social anxiety disorder. While it may lead to isolation, it does not place the client at increased risk for physical injury.

A client who has panic disorder and exhibits paresthesia: Paresthesia, such as tingling or numbness, is a common symptom during panic attacks but does not directly increase the risk for physical injury. While distressing, it typically resolves and is not associated with unsafe behaviors.

Asymptomatic HIV: Clients with asymptomatic HIV and adequate CD4 counts may safely receive the MMR vaccine. It is not contraindicated unless the client is significantly immunocompromised.

Mild febrile illness: Mild illnesses, such as low-grade fever or upper respiratory infections, do not contraindicate vaccine administration. The MMR vaccine can still be safely given, as minor illness does not significantly alter vaccine response or increase risks.

Egg allergy: Although the MMR vaccine is cultured in chick embryo fibroblasts, it does not contain significant egg protein, and studies have shown it can be safely administered to individuals with egg allergies. An egg allergy is not a valid reason to withhold the vaccine.

"Controlled substances are kept in the bottom drawer of the medication cart.":  Controlled substances are stored in locked, secure medication dispensing systems or locked drawers—not casually in the bottom drawer. Security measures are in place to prevent diversion and ensure accurate tracking.

"I should verify the number of controlled substances at the end of the shift. The provider is responsible for inventory of controlled substances.": While end-of-shift counts are standard practice, the nurse not the provider is responsible for verifying inventory at shift change. Accountability for handling and documenting controlled substances lies with nursing staff.

"Computer controlled substance inventory is reported to the Drug Enforcement Administration every 10 years.": Facilities are required to maintain records and conduct regular audits, and the DEA mandates inventory at least every 2 years not every 10. Reporting frequency and requirements are more stringent.

This image shows a newborn with normal skin tone and no visible skin lesions. There are no signs of erythema, pustules, or macules that would suggest erythema toxicum.

The newborn in this image has generally red skin, which could be due to normal newborn circulation changes or mild erythema, but it lacks the distinctive papular or pustular rash pattern seen in erythema toxicum.

Label the money with the client's name and leave it at the nurses' station: Leaving valuables at the nurses' station, even if labeled, poses a risk for loss or theft. It does not meet institutional standards for safeguarding client property and may violate facility policies.

Place the money in an envelope in the client's medication drawer: Medication drawers are intended for storing prescribed medications only. Using them for valuables is inappropriate, insecure, and may lead to misplacement or confusion during care transitions.

Hold the money for the client until their return from surgery: Personally holding the client’s money is a liability and not an accepted protocol. It lacks formal documentation and security, increasing the risk of loss or accusation of theft.