1. A nurse in the emergency room is collecting data from a client who has
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m heroin intoxication. Which of the following findings should the nurse
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m expect?
A. Seizure activity m
B. Respiratory depression m
C. Hypersensitivity to pain m m
D. Increased mental alertness m m
…Ans>> Respiratory depression
m m
*Heroin is an opioid; therefore, the nurse should expect this client who has heroin
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intoxication to exhibit respiratory depression.
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2. A nurse on a mental health unit is caring for a client who is displaying signs
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1 m/ m135
,of anger. Which of the following pieces of information about the client is the
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m strongest indicator that the client might become aggressive?
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A. The client has marginal coping skills
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B. The client has a history of violence
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C. The client feels powerless after being hospitalized
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D. The client blames others for her problems
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…Ans>> The client has a history of violence
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*The client's history of violence is the most important indicator that this client might
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become violent; therefore, this is the strongest indicator of potential aggressiveness.
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3. A nurse is reinforcing teaching with the caregiver of a client who has
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m dementia. Which of the following instructions should the nurse include in
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m theteaching?
m
A. Offer the client a list of activities to choose from
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B. Offer finger foods to the client
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C. Discourage naps throughout the day m m m m
D. Turn on the television when the client is in the room
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…Ans>> Offer finger foods to theclient
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*The caregiver should offer finger foods that the client can eat without sitting down.
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Clients who have dementia often like to wander and walk off nervous energy, which
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can decrease anxiety and calm the client.
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2 m/ m135
,4. A nurse is contributing to the plan of care for a client with bipolar disorder
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who has acute mania. Which of the following interventions should the nurse
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recommend including in the plan?
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A. Provide the client with a low-calorie, low-fat diet
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3 m/ m135
, B. Encourage the client to have frequent rest periods m m m m m m m
C. Escort the client to daily group therapy
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D. Limit the client's intake of caffeinated beverages to 12 oz per day
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…Ans>> Encouragethe client to have frequent rest periods
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*The nurse should recommend encouraging frequent rest periods throughout the
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m day to decrease the client's risk of exhaustion from the constant activity associated
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with acute mania.
m m m
5. A nurse is reviewing the plan of care for a client who has bipolar disorder.
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Which of the following is an effect of using cognitive behavioral therapy (CBT)
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for a client who has bipolar disorder?
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A. Prevents the need for mood-stabilizing medications m m m m m
B. Helps the client deal with distorted thought processes
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C. Aids in communication among family members
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D. Replaces the need for lifestyle interventions m m m m m
…Ans>> Helps the client deal with distort-ed thought processes
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*CBT assists the client with recognizing distorted thought processes that are mal-
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m adaptive with regards to recovery. When experiencing mania, the client tends to view
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the future unrealistically as highly favorable. CBT assists the client in recognizing
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m and challenging such unrealistic or "automatic" thoughts and can help the client and
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the health care team recognize early trends toward mania
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4 m/ m135
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