A client was admitted to the intensive care unit after a single car accident in which he struck a cement wall. He is now responsive and wants to be discharged within the next couple of days. Which of the following are priorities for screening? (Select all that apply)

Traumatic brain injury

Chronic pain

Sexual Dysfunction

Depression

Effective coping strategies

Risk for suicide

Answer and Explanation

Correct Answer : A,D,F

A) Correct. Given the nature of the accident, there is a high risk for traumatic brain injury. This should be a priority for screening and assessment.

B) Incorrect. While chronic pain may be a concern, it is not directly related to the recent accident and is not a priority for screening at this time.

C) Incorrect. Sexual dysfunction is not directly related to the recent accident and is not a priority for screening at this time.

D) Correct. The client's request for early discharge and the recent traumatic event raise concerns about potential depression. Screening for depression is important.

E) Incorrect. Effective coping strategies are important, but they are not a priority for screening in this scenario.

F) Correct. Given the recent accident and the client's expressed desire for early discharge, there may be an increased risk for suicide. This should be a priority for screening and assessment.

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Correct Answer is B

Explanation

A. These symptoms are not characteristic of alcohol withdrawal delirium.
B. Alcohol withdrawal delirium is characterized by symptoms such as hypertension, disorientation, and hallucinations.
C. Hypotension and bradycardia are not typically associated with alcohol withdrawal delirium. They may be seen in other types of alcohol withdrawal.
D. These symptoms are not specific to alcohol withdrawal delirium. They may be present in other forms of alcohol withdrawal.

A. Diaphoresis, piloerection, tremors, irritability, insomnia, nausea, and vomiting. B. Diaphoresis, hypertension, hand tremors, hallucination/illusions, and potential seizures. C. Cravings, depression, fatigue, hypersomnolence, and impaired judgment. D. Heightened sense of self, hallucinations, flashbacks, incoordination, and panic attacks.

Correct Answer is A

Explanation

A) Correct. These symptoms are indicative of opioid withdrawal. Opioid withdrawal symptoms include sweating (diaphoresis), goosebumps (piloerection), tremors, irritability, insomnia, and gastrointestinal symptoms like nausea and vomiting.

B) Incorrect. These symptoms are more indicative of withdrawal from substances like alcohol or benzodiazepines, rather than opioids.

C) Incorrect. These symptoms are not specific to opioid withdrawal and may be seen in various conditions.

D) Incorrect. This cluster of symptoms is not characteristic of opioid withdrawal.

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A client was admitted to the intensive care unit after a single car accident in which he struck a cement wall. He is now responsive and wants to be discharged within the next couple of days. Which of the following are priorities for screening? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse would monitor for which symptoms?

Correct Answer is B

Explanation

The nurse is caring for a client who is withdrawing from long-term use of opioids. The nurse will monitor using a Clinical Opioid Withdrawal Scale (COWS). Which of the following cluster of symptoms would indicate to the nurse the client was withdrawing from opioids?

Correct Answer is A

Explanation

A client has been prescribed lithium for long-term maintenance of bipolar disorder diagnosis. Which statement by the client shows an understanding of the medication?

The nurse is obtaining the mental health history of a newly admitted client diagnosed with schizophrenia. The client's family reports the client is hearing voices and cannot stay focused on the topic of a discussion. Which thought disturbance is the client demonstrating?

A client diagnosed with bipolar I disorder is in a manic state, rushing about the unit, and talking regularly with a flight of ideas. What is the most therapeutic intervention?

An older adult in the middle and late stages of Alzheimer's forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the client's family?

What intervention is a priority when the client is experiencing auditory hallucinations?

A physician has prescribed an antidepressant medication for a 15yearold client. Which statement would be appropriate for inclusion in medication teaching?

The nurse states in report that the client is experiencing positive symptoms of schizophrenia. What symptoms would the nurse receiving report expect to observe?

While caring for a depressed client, a nurse would evaluate the need for suicide precautions under which circumstance?