A nurse is caring for a client who was admitted to the emergency department with a blood alcohol content of 0.15 mg/dL. Which of the following conclusions should the nurse make about the client's blood alcohol content?

Correct Answer: C

Rationale: In this scenario, the correct conclusion for the nurse to make about the client's blood alcohol content (BAC) of 0.15 mg/dL is option C: "The client ingested enough alcohol to cause them to experience acute cognitive impairment." This is the correct answer because a BAC of 0.15 mg/dL indicates a high level of alcohol in the bloodstream that can lead to significant impairment of cognitive and motor functions. Option A, stating that the client needs inpatient treatment for their drinking problem, is not the most appropriate conclusion to draw solely based on the BAC level. It is important to assess the client comprehensively before recommending a specific treatment plan. Option B, suggesting that the client has a substance use disorder, is also not directly supported by the BAC level alone. While a high BAC may be indicative of alcohol misuse, a diagnosis of a substance use disorder requires a more comprehensive evaluation. Option D, indicating that the client has been a heavy drinker over the past few months, is not the best conclusion to draw solely based on the BAC level. While a high BAC may suggest recent alcohol consumption, it does not provide definitive information about the client's drinking patterns over an extended period. Educationally, this question highlights the importance of understanding the implications of different BAC levels on a client's cognitive and physical functioning. Nurses need to be able to interpret BAC levels accurately to provide appropriate care and interventions for clients who present with alcohol-related issues.

Correct Answer: A

Rationale: In this scenario, option A is the correct choice as it indicates a protective factor in the form of a positive childhood experience. The statement reflects a supportive relationship with the English teacher, which can serve as a protective factor against the negative impact of anxiety. This positive interaction can foster a sense of security and trust for the adolescent. Option B is incorrect because frequent relocations due to parents being in the military can contribute to instability and disrupt the sense of security, potentially exacerbating anxiety in the adolescent. Option C is incorrect as being born to a teenage mother may have certain challenges and stigmas attached to it, which could lead to feelings of insecurity or inadequacy for the adolescent. Option D is also incorrect as the constant worry about the health of a sibling and the parents' absence due to caregiving responsibilities can increase stress and anxiety for the adolescent. Educationally, this question highlights the importance of identifying protective factors in a patient's history that can mitigate the impact of mental health challenges. It underscores the significance of positive relationships and experiences in promoting mental well-being, especially in vulnerable populations like adolescents with anxiety disorders.

Correct Answer: D

Rationale: In the context of caring for a client with borderline personality disorder, the defense mechanism of splitting is commonly observed. Splitting is a coping mechanism where individuals see things as either all good or all bad, failing to integrate both positive and negative qualities into a cohesive whole. This can lead to challenges within the healthcare team as the client may idealize one team member while demonizing another, creating division and discord among the team. Option A, regression, involves reverting to an earlier stage of development in the face of stress. This defense mechanism is not specifically associated with creating division in the healthcare team when compared to splitting in borderline personality disorder. Option B, reaction formation, is when a person exhibits behaviors that are the opposite of their true feelings. While this defense mechanism can impact interactions, it is not typically associated with the significant division that splitting can cause. Option C, denial, involves refusing to acknowledge aspects of reality. While denial can impact treatment adherence and rapport with healthcare providers, it is not as directly linked to creating division among the healthcare team as splitting is in borderline personality disorder. Educationally, understanding defense mechanisms in psychiatric disorders is crucial for nurses to provide effective, empathetic care. By recognizing the impact of splitting in clients with borderline personality disorder, nurses can work to foster collaboration within the healthcare team and mitigate potential conflicts that may arise.

Correct Answer: B

Rationale: The correct response is option B: "This must be a difficult time for you. Adolescents who have experienced a trauma may exhibit increased reckless behaviors." This response demonstrates empathy and understanding towards the parent's concerns while also providing crucial information about how trauma can manifest in adolescents, leading to reckless behaviors. Option A is incorrect as it focuses on comparing the behavior of the affected child to other siblings and places blame on the parent's established rules, which may not be relevant in this context of trauma. Option C is incorrect as it dismisses the concerning behaviors as normal adolescent behavior, failing to address the underlying trauma and potential need for intervention and support. Option D is also incorrect as it does not directly acknowledge the impact of trauma on the adolescent's behavior and shifts the focus solely to the parent's concerns without providing psychoeducation on trauma responses in adolescents. In an educational context, it is vital for psychiatric nurses to not only address the immediate concerns of parents but also provide psychoeducation on how trauma can affect adolescent behavior. Understanding these dynamics is crucial in providing effective support and interventions for both the adolescent and their family.

Correct Answer: B

Rationale: In this scenario, the correct nursing diagnosis that would likely apply to both a patient diagnosed with schizophrenia and a patient diagnosed with amphetamine-induced psychosis is option B) Disturbed thought processes. Educational Rationale: 1. **Correct Answer Justification:** Disturbed thought processes are a common symptom in both schizophrenia and amphetamine-induced psychosis. Both conditions can lead to disorganized thinking, delusions, and hallucinations, indicating a disruption in cognitive functioning. 2. **Why Others are Incorrect:** - A) Powerlessness: While powerlessness may be a relevant nursing diagnosis in certain situations, it is not directly associated with the cognitive disturbances seen in schizophrenia and amphetamine-induced psychosis. - C) Ineffective thermoregulation: This option is unrelated to the cognitive symptoms present in both conditions and is more commonly associated with issues related to body temperature regulation. - D) Impaired oral mucous membrane: This option pertains to physical health issues related to the oral cavity and is not directly linked to the cognitive disturbances characteristic of schizophrenia and amphetamine-induced psychosis. 3. **Educational Context:** Understanding the common nursing diagnoses across different psychiatric conditions is crucial for nurses working with patients experiencing mental health issues. By recognizing shared symptoms and appropriate nursing interventions, nurses can provide holistic care tailored to each individual's needs, promoting better patient outcomes and overall well-being.