Extract:

Question 1 of 5

A client is brought to the emergency department by a friend who states, 'He's been using a lot of heroin until he ran out of money about 2 days ago.' The nurse judges the client to be in opioid withdrawal if he exhibits which of the following? Select all that apply.

Correct Answer: A, B, C

Rationale: Opioid withdrawal symptoms include rhinorrhea (
A), diaphoresis (
B), and piloerection (
C). Synesthesia and formication are not typical of opioid withdrawal.

Question 2 of 5

Which of the following represents a breach of the nursing Code of Ethics regarding the rights of clients in psychiatric care situations?

A. Nurse discusses client's care with out-of-town family members that the client has formally indicated are allowed to know about the client's hospital care. B. Nurse discusses the client's history and hospital course of treatment with a consulting physician. C. Nurse discusses with a friend the progress of a local celebrity being cared for at the hospital. D. Nurse discusses the client's care with the admissions director for a retirement community the client has to enter after discharge from the hospital.

Correct Answer: C

Rationale: Discussing a client's care with a friend violates confidentiality, breaching the Code of Ethics.

Question 3 of 5

A client diagnosed with bipolar disorder asks the nurse why it is necessary to have a serum lithium level drawn every 3 to 4 months. The nurse's response should be based on which of the following?

A. To monitor compliance with the medication. B. To prevent toxicity related to the drug's therapeutic range. C. To monitor the client's white blood cell count. D. To comply with the drug manufacturer's requirements.

Correct Answer: B

Rationale: Regular lithium levels prevent toxicity due to its narrow therapeutic range (0.6–1.2 mEq/L).

Question 4 of 5

A client diagnosed with schizophrenia is being switched to risperidone long-acting injection (Risperdal Consta). He is told that he will remain on his oral dose of risperidone (Risperdal) daily for approximately 1 month. The client says, 'I didn't have to do this with my last shot.' Which response by the nurse is most appropriate?

A. Risperdal Consta takes a few weeks to reach a steady state in your body.' B. Your doctor wants to make sure you're stable on the oral dose first.' C. The injection and oral doses work differently for your symptoms.' D. This is a precaution to prevent side effects from the injection.'

Correct Answer: A

Rationale: Explaining that Risperdal Consta requires time to reach therapeutic levels clarifies why the oral dose is continued, addressing the client's confusion accurately.

Question 5 of 5

The nurse discusses the possibility of a client's attending day treatment for clients with Alzheimer's disease. Which of the following is the best rationale for encouraging day treatment?

A. The client would have more structure to his day. B. Staff are excellent in the treatment they offer clients. C. The client would benefit from increased social interaction. D. The family would have more time to engage in their daily activities.

Correct Answer: C

Rationale: Increased social interaction in day treatment helps reduce isolation and may slow cognitive decline in Alzheimer's, making it the primary therapeutic benefit.