Extract:

Question 1 of 5

An outpatient client who has a history of paranoid schizophrenia and chronic alcohol dependency has been taking risperidone (Risperdal) for several months. She reports that she stopped drinking 4 days ago, the client is a very satisfied by the tactile hallucinations of bugs crawling under her skin. Which of the following factors should the nurse incorporate into the plan of care when explaining the tactile hallucinations?

Correct Answer: C

Rationale: Tactile hallucinations, such as feeling bugs crawling under the skin, are commonly associated with alcohol withdrawal, especially 4 days after cessation, and should be addressed in the care plan.

Question 2 of 5

A client was admitted to the inpatient unit 3 days ago with a flat affect, psychomotor retardation, anorexia, hopelessness, and suicidal ideation. The physician prescribed 75 mg of venlafaxine extended release (Effexor XR) to be given every morning. The client interacted minimally with the staff and spent most of the day in his room. As the nurse enters the unit at the beginning of the evening shift, the client is smiling and cheerfully greets the nurse. He appears to be relaxed and joins the group for community meeting before supper. What should the nurse interpret as the most likely cause of the client's behavior?

A. The author is helping the client's symptoms of depression significantly. B. The client's sudden improvement calls for close observation by the staff. C. The staff can decrease their observation of the client. D. The client is nearing discharge due to the improvement of his symptoms.

Correct Answer: B

Rationale: Sudden improvement in a suicidal client may indicate a resolved decision to act on suicidal thoughts, requiring close observation.

Question 3 of 5

A client is entering the alcohol treatment program for the fourth time in 5 years. Which of the following statements by the nurse will be most helpful to the client?

A. I hope you are serious about maintaining your sobriety this time.' B. I'm Maria, a nurse here. I don't know you from past attempts but you'll get it right this time.' C. I know someone who was successful after the fifth program.' D. I'm Maria, a nurse in the program. The staff and I will help you through the program.'

Correct Answer: D

Rationale: Saying 'The staff and I will help you through the program' is most helpful, as it offers support, fosters collaboration, and avoids judgment about past attempts.

Question 4 of 5

Which of the following should the nurse use as the best measure to determine a client's progress in rehabilitation?

A. The kinds of friends he makes. B. The number of drug-free days he has. C. The way he gets along with his parents. D. The amount of responsibility his job entails.

Correct Answer: B

Rationale: The number of drug-free days is the best measure, as it directly reflects sustained abstinence, a primary goal of rehabilitation.

Question 5 of 5

A client in a general hospital is to undergo surgery in 2 days. He is experiencing moderate anxiety about the procedure and its outcome. To help the client reduce his anxiety, the nurse should:

A. Tell the client to distract himself with games and television. B. Reassure the client that he will come through surgery without incident. C. Explain the surgical procedure to the client and what happens before and after surgery. D. Ask the surgeon to offer the client to a psychiatrist who can work with the client to diminish his anxiety.

Correct Answer: C

Rationale: An explanation of what to expect decreases anxiety about upcoming events that could be seen as traumatic by the client. Distraction, such as games or television, may not address the specific anxiety related to the surgery. Reassuring the client without providing information may seem dismissive and does not empower the client with knowledge. Referring to a psychiatrist is unnecessary for moderate anxiety and may delay immediate anxiety reduction.