A male client with a long history of alcohol dependency arrives in the Emergency Department describing the feeling of bugs crawling on his body. His blood pressure is 170/102 mm Hg, pulse rate is 110 beats/minute, and blood alcohol level (BAL) is 0 mg/dL. Which prescription should the nurse administer?

Haloperidol.

Lorazepam.

Diphenyhydramine.

Thiamine.

Answer and Explanation

The Correct Answer is B

A) Haloperidol is an antipsychotic that may be used for agitation or hallucinations, but it is not the first-line treatment for alcohol withdrawal symptoms. Administering haloperidol without addressing withdrawal may not be effective and could lead to further complications.

B) Lorazepam is a benzodiazepine and is the preferred medication for managing alcohol withdrawal symptoms, including agitation, anxiety, and hallucinations. It helps reduce the risk of severe withdrawal symptoms and seizures while providing sedative effects. Given the client’s symptoms of feeling bugs crawling on his body, which may indicate tactile hallucinations due to withdrawal, lorazepam would be the most appropriate choice.

C) Diphenhydramine is an antihistamine that can be used for allergic reactions or as a sedative, but it is not effective for managing alcohol withdrawal symptoms.

D) Thiamine is important to prevent Wernicke's encephalopathy in clients with a history of alcohol dependency, especially if there are signs of confusion or neurological deficits. However, it does not address the immediate symptoms of withdrawal the client is experiencing.

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Correct Answer is ["C","D","E"]

Explanation

A) Grandiosity is not typically associated with postpartum depression. Instead, it is more commonly seen in conditions such as mania or bipolar disorder. This finding would not be consistent with postpartum depression.

B) Compulsive behavior may occur in various mental health conditions, but it is not a core symptom of postpartum depression. This symptom would need further evaluation to determine its relevance in this context.

C) Sadness is a hallmark symptom of postpartum depression. Clients often report feelings of intense sadness and hopelessness, making this a key finding in the assessment.

D) Poor concentration is commonly observed in postpartum depression. Many clients experience difficulties with focus and decision-making, which can be distressing and interfere with daily functioning.

E) Disrupted sleep is another significant symptom associated with postpartum depression. Clients may experience insomnia or altered sleep patterns, which can exacerbate feelings of fatigue and sadness.

A. Disturbed personal identity. B. Risk for injury. C. Ineffective coping. D. Anxiety, panic.

Correct Answer is B

Explanation

A) Disturbed personal identity could be relevant in the context of a mental health issue, but it is not the most immediate concern given the client's current presentation. While it may be important to address over time, it does not take precedence in the acute phase.

B) Risk for injury is the most critical problem to include in the client's plan of care. The client's lack of sleep, pressured speech, and increase in sexual promiscuity indicate a potential manic episode, which can lead to impulsive and unsafe behaviors. Prioritizing the risk for injury ensures the safety of the client and others, making it essential for the immediate care plan.

C) Ineffective coping is a concern that may develop in response to the client's current symptoms. However, addressing immediate safety needs is more urgent than focusing on coping mechanisms at this point.

D) Anxiety and panic might be present, but they are not as clearly defined in the client's current symptoms as the risk for injury. The focus should remain on preventing harm and ensuring the client is safe during this acute episode.

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a client with postpartum depression for changes in the mood and cognitive state. Which subjective finding(s) should the nurse identify that are consistent with postpartum depression? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

The nurse is admitting a client who has not slept in three days to the inpatient care facility. The client has pressured speech and describes an increase in sexual promiscuity. Which problem should the nurse include in the client's plan of care?

Correct Answer is B

Explanation

A client with opioid dependence makes a statement to the nurse about desiring to lead a healthier lifestyle by making changes in the next 2 weeks. How should the nurse respond?

A young adult client is brought to the emergency department with a suspected drug overdose. Which information is most important for the nurse to obtain from the family?

The nurse interacts with a client who is very depressed and slow to respond to questions. The nurse asks the client to describe current feelings, but the client looks down at the table. Which action is best for the nurse to implement?

An older adult woman who lives in a long-term mental health facility has a history of taking belongings from other clients' rooms when she becomes agitated. The client is found placing these items in the same closet on the unit. Which action should the nurse take?

A client with bipolar disorder has not slept or eaten in four days. The client is pacing and becomes increasingly agitated and loud while the nurse talks to the client's spouse. Which intervention is best for the nurse to implement at this time?

The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?