health Assessment Complete Questions & Verified Correct Answers |
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The client is using reaction formation when unacceptable behaviors are controlled and
kept out of awareness by developing the opposite behavior. This is an adaptive use of
the defense mechanism.
A nurse is caring for a client who is in recovery from a substance use disorder and is
receiving treatment for withdrawal from heroin. Which of the following manifestations
should the nurse expect?
Bradycardia
Hypertension
Slurred speech
Pinpoint pupils -answer-Hypertension;
Hypertension is a manifestation of opioid withdrawal. Additionally, a client who is
experiencing withdrawal can experience tachycardia, hyperthermia, and tachypnea.
A nurse is assessing a client who has a prescription for fluoxetine. Which of the
following findings is a potential adverse effect of the medication?
Urinary retention
Bradycardia
Increased temperature
Orthostatic hypotension -answer-Increased temperature;
Hyperpyrexia or fever is a potential adverse effect of fluoxetine. Serotonin syndrome is
a rare life-threatening occurrence associated with SSRIs. The effects include fever,
tachycardia, elevated blood pressure, sweating, diarrhea, delirium, mood swings,
hostility, seizures, apnea, and possible death.
,A nurse is assessing a client who is taking lithium. For which of the following findings
should the nurse notify the provider?
Blood pressure 118/70 mm Hg
Weight loss of 2 kg (4.4 lb) in 1 month
Client report of sleeping 8 hr per night
Coarse tremors of the hands -answer-Coarse tremors of the hands;
Coarse tremors of the hands are a manifestation of lithium toxicity. Other manifestations
include polyuria, muscle weakness, slurred speech, and sedation. The nurse should
notify the provider of this finding so laboratory tests can be prescribed.
A nurse is teaching a client who has a new prescription for clozapine about the potential
adverse effects of the medication. Which of the following conditions should the nurse
include in the teaching?
Hair loss
Sore throat
Loss of appetite
Metallic taste in the mouth -answer-Sore throat;
Clozapine can cause agranulocytosis. Manifestations of agranulocytosis includes signs
of infections such as chills, sore throat, and fever. The client should have complete
blood counts to monitor WBC count and absolute neutrophil count (ANC) routinely.
Registered dietitians review a client's nutritional needs and adjust the clients diet based
upon laboratory findings, medication adverse effects, and dietary intake. -answer-
a nurse is collecting data from a client who received diazepam 10mg PO 1 hr ago.
which of the following findings should the nurse identify as an indication that the client is
experiencing benzodiazepine toxicity? -answer-respiratory rate 10/min
a nurse is interviewing an adolescent client who reports that they were sexually
assaulted. which of the following actions should the nurse take? -answer-move the
client to a private examination room to perform the interview.
A nurse is reinforcing teaching with a client who has schizophrenia and new prescription
for fluphenazine. which of the following adverse effects should the nurse include in the
teaching -answer-akathisia, hypotension, drowsiness
a nurse is reinforcing discharge teaching with the family of a client who has mild
dementia. the family plans to care for the client in their home. which of the following
instructions should the nurse include? -answer-use signs to identify different rooms in
the home
, a nurse is reinforcing teaching with a client who is preparing for a conditional release
following involuntary admission. which of the following statements by the client indicates
an understanding of the teaching. -answer-If I don't follow the instructions in my
conditional release, I might be readmitted
a nurse is assisting with the care of a client immediately following electroconvulsive
therapy (ECT), which of the following findings should the nurse document as an
unexpected response to the procedure -answer-Irregular heart rhythm
a nurse is planning an in-service about eating disorders for a group of staff nurses.
which of the following conditions should the nurse include as a risk factor for anorexia
nervosa? -answer-a diagnosis of obsessive-complusive disorder
a nurse is reinforcing discharge teaching with a client who has alcohol use disorder.
which of the following statements by the client indicates an understanding of relapse
prevention -answer-I'm learning which situations I have difficulty handling
a nurse is reinforcing teaching regarding family therapy with the parents of a client who
has anorexia nervosa. the parents tell the nurse, " we don't understand why we have to
have family therapy we are not sick". which of the following responses should the nurse
provide -answer-family therapy explores how the family dynamic impact your son
a nurse is reinforcing discharge instructions with a client who has bipolar disorder and is
taking lithium. which of the following statements by the client indicates an understanding
of the teaching -answer-I will have the level of medication in my blood checked
regularly
a nurse is collecting data from a client who has schizophrenia. when asked questions,
the client keeps repeating what the nurse says rather than providing answers. the nurse
should document this finding as which of the following alterations of speech -answer-
echolalia
a nurse is contributing to the plan of care for a client who has anorexia nervosa and is
60% of their ideal body weight (IBW).
which of the following interventions should the nurse include -answer-set structured
mealtimes for the client
a nurse is caring for a client who is experiencing acute alcohol withdrawal. the client
becomes agitated and the nurse administers lorazepam 2 mg IM. which of the following
actions should the nurses take -answer-ensure a staff member remains with the client
continuously
a nurse is caring for a client who is obese and states, " I need to lose weight to be
attractive again." which of the following actions should the nurse take first to promote
positive self-esteem. -answer-ask the client how they feel about their weight and
appearance