A patient asks for information about Alcoholics Anonymous (AA). Which is the nurse’s best response?

Correct Answer: A

Rationale: The correct answer is A: "It is a self-help group with the goal of sobriety." This is the best response because Alcoholics Anonymous (AA) is indeed a self-help group focused on achieving and maintaining sobriety through shared experiences and support. Choice B is incorrect because AA is not led by a psychiatrist but rather by individuals who are also in recovery. Choice C is incorrect as AA does not focus on learning about drinking but rather on supporting recovery. Choice D is incorrect as AA does not advocate for punishment but rather emphasizes compassion and understanding towards individuals struggling with alcohol addiction.

Correct Answer: A

Rationale: The correct answer is A: Monitor the airway and vital signs every 15 minutes. After administering naloxone to a patient with an opiate overdose, it is crucial to monitor the patient's airway and vital signs regularly to assess for respiratory depression, potential re-sedation, and other adverse effects of naloxone. This intervention ensures the patient's safety and allows for prompt detection and management of any complications. Choice B is incorrect because inserting a nasogastric tube and testing gastric pH is not indicated after naloxone administration for opiate overdose. Choice C is incorrect as treating hyperpyrexia with cooling measures is not a priority intervention in this scenario. Choice D is also incorrect as inserting an indwelling urinary catheter is not necessary after administering naloxone for opiate overdose.

Correct Answer: C

Rationale: The correct answer is C because the assessment findings of nausea, vomiting, diaphoresis, anxiety, and tremors are classic symptoms of withdrawal from central nervous system depressants such as alcohol or benzodiazepines. Nausea and vomiting can result from the body's attempt to expel the toxic substance, diaphoresis can occur due to increased sympathetic activity, anxiety and tremors are common manifestations of central nervous system hyperactivity during withdrawal. The other choices (A, B, D) do not align with the typical withdrawal symptoms of CNS depressants and are more indicative of other conditions or substances.

Correct Answer: A

Rationale: The correct answer is A because for a patient who has ingested LSD, it is important to have someone stay with them and provide verbal support due to the potential for anxiety and panic attacks. This helps in grounding the patient and providing reassurance. On the other hand, for a patient who has ingested PCP, a regimen of limited contact with staff members is maintained to prevent potential aggression or unpredictable behavior. Continual visual monitoring is provided to ensure safety without directly engaging with the patient. Choice B is incorrect because placing a patient on one-on-one intensive supervision for PCP ingestion may escalate the situation due to potential paranoia or aggression. Choice C is incorrect because LSD ingestion may lead to sensory overload, so providing moderate sensory stimulation is more appropriate. Choice D is incorrect because restraints for LSD ingestion are not necessary and seizure precautions are not typically needed for PCP ingestion.

Correct Answer: A

Rationale: The correct answer is A: Chronic low self-esteem. The patient's statement reflects long-standing feelings of inadequacy and worthlessness, indicating a chronic issue rather than a temporary situation (situational low self-esteem). The statement also reveals a negative perception of self, which aligns with chronic low self-esteem. Disturbed personal identity refers to confusion in one's sense of self, which is not evident in the patient's statement. Ineffective health maintenance pertains to the inability to identify, manage, and seek help for health problems, which is not the primary issue in this scenario. Therefore, A is the most appropriate nursing diagnosis.