1. A nurse is collecting data from a client who is experiencing alcohol with-
drawal. Which of the following manifestations should the nurse expect?:
Di- aphoresis
The nurse should expect a client who is experiencing alcohol
withdrawal to experi- ence diaphoresis, or increased sweating.
2. A nurse in a long-term care center is caring for an adult client who has
Alzheimer's disease and whose partner died several years ago. The client
appears upset and asks the nurse when his partner will visit again. The
nurse states, "It seems like you are feeling lonely. Let's take a walk outside
and talk." Which of the following communication strategies is the nurse
using?: Valida- tion therapy
The nurse is using validation therapy as a strategy to communicate with
the client. This strategy validates the client's feelings and emotions,
even when they don't co- incide with reality. The nurse should also
attempt to integrate redirection techniques without the client realizing
he is being redirected.
3. A nurse is reinforcing teaching with a client who has schizophrenia
and a new prescription for chlorpromazine. Which of the following
1/
,statements
should the nurse include in the teaching?: "The voices you have been
hearing should decrease"
The nurse should instruct the client that hallucinations and agitated
behavior, which are positive symptoms of schizophrenia, are targeted
by conventional antipsychotic agents, such as chlorpromazine.
4. A nurse is reinforcing teaching with a client who has generalized anxiety
disorder and is to start therapy with buspirone. Which of the following state-
ments should the nurse identify as an indication that the client understands
the information?: "I should expect some improvement of my symptoms
in about 10 days."
The nurse should instruct the client to expect some improvement of
symptoms after 7 to 10 days. However, it takes 2 to 4 weeks for
buspirone to reach its full effect.
5. A nurse is caring for a client who has major depressive disorder (MDD).
The client states, "I have nothing to live for anymore. I just can't go on."
Which
of the following responses should the nurse make?: "Are you thinking
about ending your life?"
2/
, The nurse should identify that this client's safety is at risk. The client's
statement is an overt statement that indicates hopelessness, which
increases the risk of suicide for a client who has MDD. It is imperative
that the nurse immediately evaluate the client for suicidal ideation.
6. A nurse at an outpatient mental health clinic is assisting with a group
therapy session. One of the participants is having difficulty staying
seated
3/
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