A client with mania begins dancing around the day room. When she twirled her skirt in front of the male clients, it was obvious she had no underpants on. The nurse distracts her and takes her to her room to put on underpants. The nurse acted as she did to:
Avoid embarrassing the male clients who are watching.
Keep her from dancing with other clients.
Teach her about proper attire and hygiene.
Minimize the client's embarrassment about her present behavior.
The Correct Answer is D
Choice A reason: This is incorrect because the nurse’s primary responsibility is to protect the client, not the male clients.
Choice B reason: This is inaccurate because the nurse’s intervention was not about stopping dancing but about addressing inappropriate exposure.
Choice C reason: This is incorrect because the nurse’s immediate action was not a teaching moment but a protective intervention. Teaching can occur later when the client is stable.
Choice D reason: This is correct because the nurse acted to protect the client’s dignity and minimize embarrassment. Clients with mania often lack awareness of socially inappropriate behavior, and the nurse’s intervention helps maintain safety and dignity without confrontation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E","F"]
Explanation
Choice A reason: Lethargy is not a typical sign of alcohol withdrawal. Instead, withdrawal is characterized by hyperactivity of the autonomic nervous system, not sedation or fatigue. Lethargy is more often seen with intoxication rather than withdrawal.
Choice B reason: Blackouts occur during episodes of heavy drinking due to acute intoxication and memory impairment, not during withdrawal. Withdrawal symptoms are related to the absence of alcohol and the rebound hyperexcitability of the nervous system.
Choice C reason: Nausea is a common symptom of alcohol withdrawal. The gastrointestinal system becomes irritated, and autonomic hyperactivity contributes to nausea and vomiting. This is a well-recognized clinical feature.
Choice D reason: Tremulousness, or hand tremors, is one of the hallmark signs of alcohol withdrawal. It results from central nervous system hyperexcitability when alcohol is abruptly discontinued. Tremors are often the first noticeable symptom.
Choice E reason: Diaphoresis, or excessive sweating, is a classic autonomic symptom of alcohol withdrawal. It reflects increased sympathetic nervous system activity, which is a direct consequence of withdrawal.
Choice F reason: Elevated blood pressure is another autonomic sign of alcohol withdrawal. The absence of alcohol leads to increased sympathetic tone, causing hypertension and tachycardia. This is a critical sign to monitor because it can progress to more severe complications such as seizures or delirium tremens.
Correct Answer is D
Explanation
Choice A reason: Relaxed inhibitions, increased appetite, and distorted perceptions are more characteristic of cannabis intoxication rather than stimulants. Cannabis use often leads to increased appetite ("the munchies") and perceptual distortions, but stimulants typically suppress appetite and increase alertness.
Choice B reason: Depersonalization, dilated pupils, and visual hallucinations are more consistent with hallucinogen intoxication such as LSD or PCP. While stimulants can cause dilated pupils, the presence of depersonalization and hallucinations points more toward hallucinogens rather than stimulants.
Choice C reason: Slurred speech, unsteady gait, and impaired concentration are typical of alcohol intoxication or sedative-hypnotic use. These substances depress the central nervous system, leading to impaired motor coordination and speech, which are not features of stimulant intoxication.
Choice D reason: Hyperactivity, talkativeness, and euphoria are hallmark signs of stimulant intoxication. Stimulants such as cocaine, amphetamines, and methamphetamine increase dopamine and norepinephrine activity, leading to heightened energy, excessive talking, and feelings of intense pleasure or euphoria. These behaviors directly reflect the pharmacologic effects of stimulants on the central nervous system.
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