RAT: Hypertension is an expected finding of alcohol withdrawal and can
occur within 4 to 12 hr of cessation of alcohol ingestion.
A nurse is caring for a client who recently lost their child in a motor-
vehicle crash. The client is expressing feelings of hopelessness. Which of
the following questions is the most important for the nurse to ask?
• "Are there times when you feel more upset than others?"
• "Have you had any thoughts of harming yourself?"
• "What type of support system do you currently have?"
• "During difficult times in the past, what did you
do to cope?"
• (Ans- B. "Have you had any thoughts of harming
yourself?"
RAT: The greatest risk to this client is self-injury due to suicide.
Asking whether or not the client has plans to hurt themselves is the most
important question for the nurse to ask at this time because a positive
response can alert the nurse to the need for suicide precautions and
intervention.
A nurse is reviewing the medical record of a client who has schizophrenia.
For which of the following findings should the nurse withhold the client's
medications and notify the provider?
• Fasting blood glucose
,• Temperature
• WBC count
• Heart rate
(Ans- C. WBC count
RAT: The nurse should identify that a WBC count of 3,000/mm3 is below the
expected reference range of 5,000 to 10,000/mm3. The nurse should
identify that clozapine can cause agranulocytosis, a decrease in white
blood cells, which can be life threatening.
Therefore, the nurse should withhold the client's medications and notify
the provider of this finding.
A nurse is collecting data from a client whose home was destroyed by a
fire. Which of the following responses should the nurse make first?
• "Are you experiencing feelings of hopelessness?"
• "Is there someone I can call for you?"
• "It might be helpful for you to attend a support group."
• "Now is a good time for you to use relaxation
breathing."
• (Ans- A. "Are you experiencing feelings of
hopelessness?"
RAT: When using Maslow's hierarchy of needs, the priority action for the
nurse to take is to determine if the client is safe. The nurse should
collect data about the client's feelings to determine if the client is
having feelings of hopelessness or suicidal ideations.
A nurse is collecting data from a client who is taking valproic acid for the
treatment of a bipolar disorder. Which of the following findings is the
priority to the provider?
• Dizziness
• Weight gain
• Constipation
• Yellow sclerae
(Ans- D. Yellow sclerae
, RAT: When using the urgent vs. nonurgent approach to client care, the nurse
should determine that the priority finding is yellow sclerae because of the
risk for hepatotoxicity.
A nurse is reinforcing teaching about food that contains tyramine with a
client who has a prescription for phenelzine. Which of the following foods
should the nurse instruct the client to void?
RAT: Smoked sausages are high in tyramine. Clients who are prescribed
monoamine oxidase inhibitors (MAOIs) should avoid food that contain tyramine
because consuming them can cause a hypertensive crisis.
A nurse is attempting to resolve an ethical dilemma that involves a
client's medical decisions and their own personal values. After collecting
data and identifying the problem, which of the following actions should
the nurse take next?
• Discuss information about the dilemma with the client's provider.
• Determine the benefits and consequences of respecting the
client's medical decisions.
• Reflect on the effect of ethical theories on the nurse's personal values.
• Develop a plan that balances both the nurse's values and the
client's medical decisions.
(Ans- B. Determine the benefits and consequences of respecting the client's
medical decisions.
RAT: After the nurse collects the data and identifies the problem, the
nurse should determine the benefits and consequences of respecting the
client's medical decisions as the next step in the ethical decision-making
model.
A nurse is reinforcing teaching to a client who has a new prescription for
phenelzine. The nurse should instruct the client that eating foods high in
tyramine can cause which of the following adverse reactions with this
medication?
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