A client with a history of opioid abuse is exhibiting manifestations of moderate withdrawal. Which of the following would the nurse expect to assess?

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ATI Mental Health Capstone Assessment Questions

Question 1 of 5

A client with a history of opioid abuse is exhibiting manifestations of moderate withdrawal. Which of the following would the nurse expect to assess?

Correct Answer: C

Rationale: The correct answer is C: Dilated pupils. Opioid withdrawal commonly presents with dilated pupils due to the noradrenergic rebound effect. This occurs as the body tries to compensate for the suppression of noradrenaline caused by chronic opioid use. Rhinorrhea and lacrimation are associated with opioid withdrawal but are typically seen in early withdrawal stages. Dysphoria is a common symptom in opioid withdrawal but is not specific to moderate withdrawal.

Question 2 of 5

A patient with an abdominal mass is scheduled for a biopsy. The patient has difficulty understanding the nurse's comments and asks, "What do you mean? What are they going to do?" Assessment findings include tremulous voice, respirations 28, and pulse 110. What is the patient's level of anxiety?

Correct Answer: B

Rationale: The correct answer is B: Moderate. The patient's tremulous voice, increased respirations, and elevated pulse indicate a moderate level of anxiety. These physiological signs suggest heightened stress and arousal, which are characteristic of moderate anxiety. Mild anxiety would not typically present with such pronounced physical symptoms. Severe anxiety would exhibit even more severe physical manifestations, while panic anxiety would involve extreme distress and potential loss of control.

Question 3 of 5

Demanding proof from the client is to"challenging" as persistent questioning of the client and pushing for answers the client does not wish to discuss is to:

Correct Answer: D

Rationale: The correct answer is D: "Probing." Probing involves persistently questioning and pushing for answers from the client, similar to how demanding proof challenges the client. Probing seeks to uncover deeper insights or information, even if the client may not initially wish to discuss it. A: "Advising" is incorrect because advising involves offering guidance or recommendations to the client, which is different from persistent questioning. B: "Defending" is incorrect as it involves supporting or justifying the client's actions or positions, not pushing for more information. C: "Rejecting" is incorrect as it involves dismissing or refusing the client's input or requests, not actively seeking more information like probing does.

Question 4 of 5

The nurse is assessing an 8-year-old child's self-concept. Which of the following would be least appropriate for the nurse to ask?

Correct Answer: D

Rationale: The correct answer is D because asking about breakfast is unrelated to self-concept assessment. Choices A, B, and C are relevant as they explore the child's aspirations, interests, and self-perception. Breakfast is a daily routine and does not provide insights into the child's self-concept. It is important for the nurse to focus on questions that directly relate to the child's thoughts, feelings, and perceptions of themselves rather than their daily activities.

Question 5 of 5

A nurse is working for a mobile homeless treatment program. Which method would the nurse most likely use to provide follow-up care to clients?

Correct Answer: B

Rationale: The correct answer is B, riding a bicycle to wherever the client happens to be. This method is most likely used for follow-up care in a mobile homeless treatment program because it allows the nurse to reach clients who may not have consistent access to transportation or a fixed address. By being mobile, the nurse can ensure continuity of care and provide services directly to clients in their own environment. Option A, seeing them by appointment at a clinic office, may not be feasible for homeless clients due to transportation and scheduling challenges. Option C, meeting the client in a public place easily accessible by taxi, may not be practical if the client's location changes frequently. Option D, using the telephone to determine how well the clients are doing, lacks the personal connection and hands-on assessment that may be necessary for providing effective follow-up care in this setting.

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