A nurse is caring for a patient who is experiencing withdrawal from alcohol. Which of the following symptoms should the nurse monitor for?

Correct Answer: B

Rationale: The correct answer is B because severe agitation, tremors, and seizures are common symptoms of alcohol withdrawal, known as delirium tremens, which can be life-threatening. These symptoms indicate hyperactivity of the central nervous system due to alcohol withdrawal. Monitoring for these symptoms is crucial for early intervention and preventing potential complications. A: Fatigue and lethargy are not typically associated with alcohol withdrawal. C: Headaches and nausea are common symptoms of alcohol withdrawal but are not indicative of severe withdrawal requiring immediate intervention. D: Increased appetite and weight gain are not symptoms of alcohol withdrawal; in fact, weight loss is more common due to decreased appetite and malnutrition during withdrawal.

Correct Answer: B

Rationale: The correct answer is B: Providing a calm, quiet environment. During a depressive episode in bipolar disorder, the patient may feel overwhelmed and agitated. Providing a calm, quiet environment can help reduce stress and promote relaxation, which is beneficial in managing depressive symptoms. Other choices are incorrect because group therapy (choice A) may be overwhelming, reassuring the symptoms will resolve (choice C) may minimize the severity of the condition, and encouraging social activities (choice D) may be too demanding for the patient during a depressive episode.

Correct Answer: A

Rationale: Accepting the handmade card of appreciation from Becky is appropriate as it is a gesture of gratitude for the care provided. It helps foster a positive therapeutic relationship and validates the impact of your care. Rejecting it could potentially hurt Becky's feelings and undermine the trust and rapport built during her care. State laws or her illness are not relevant factors in this scenario. Accepting the card aligns with ethical principles of compassion and human connection.

Correct Answer: B

Rationale: The correct answer is B: No. The nurse cannot disclose information to the surviving spouse. As a healthcare professional, the nurse is bound by patient confidentiality even after the patient's death. The information regarding sexual abuse is considered confidential and cannot be shared without the patient's consent. Revealing such sensitive information without the patient's permission would violate the client's privacy rights and ethical principles of confidentiality. It is crucial to uphold confidentiality to maintain trust and protect the client's dignity, even after their passing. Choices A and C are incorrect because they suggest disclosing information without considering the legal and ethical implications. Choice D is incorrect as the decision should not be based on subjective feelings but on established principles of confidentiality and ethical guidelines.

Correct Answer: A

Rationale: Step 1: Nurse-initiated interventions are actions that nurses can initiate independently based on their scope of practice. Step 2: State Nurse Practice Acts define the scope of practice for nurses, including what interventions they can independently initiate. Step 3: Therefore, nurse-initiated interventions are determined by state Nurse Practice Acts (Choice A). Summary: Choices B, C, and D are incorrect because nurse-initiated interventions are not necessarily supervised by the entire health care team, made in concert with physician-initiated plans, or developed after evaluating medical diagnoses. The correct answer is A because it aligns with the principle of nurses working within their scope of practice.