A nurse is counseling a client with alcoholism who has been abusive to their children. The nurse experienced a similar situation in childhood and states to the client, "How can you mistreat a child?" Which is the best way for the nurse to deal with the countertransference displayed? (Select all that apply.)

Consider a transfer to a unit that does not require counseling of clients.

Request that another nurse take over the counseling session with the client.

Discuss with the client the issues surrounding the response made.

The nurse should examine feelings and responses prior to counseling.

Talking about feelings and emotions with a trusted colleague.

Answer and Explanation

Correct Answer : B,D,E

Choice A reason: Considering a transfer might avoid the immediate issue but does not address the nurse's countertransference or promote professional growth.

Choice B reason: Requesting another nurse to take over may be appropriate to ensure the client receives unbiased care while the original nurse addresses their countertransference.

Choice C reason: Discussing personal issues with the client is not appropriate as it can blur professional boundaries and may not be therapeutic for the client.

Choice D reason: The nurse should examine their feelings and responses to prevent personal experiences from affecting professional judgment and interactions with clients.

Choice E reason: Talking about feelings and emotions with a trusted colleague can provide support and help the nurse process their feelings in a safe environment.

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

Explanation

Choice A Reason:

Checking the client's pupil reactivity is important because alcohol intoxication can affect the nervous system, which may be reflected in changes in pupil size and reactivity to light. Normal pupil size ranges from about 2 to 4 mm in diameter in bright light to 4 to 8 mm in the dark. Pupils that do not respond to light could indicate a neurological deficit that requires immediate attention.

Choice B Reason:

Performing a developmental screening test is not typically indicated for acute alcohol intoxication management. Developmental screenings are generally used to assess children for appropriate growth and developmental milestones, not for adults in an emergency setting due to intoxication.

Choice C Reason:

Preparing the client for a CT scan may be necessary if there is a suspicion of head trauma or intracranial bleeding, which can occur with falls or injuries associated with intoxication. A CT scan can help identify any urgent issues that need to be addressed.

Choice D Reason:

Obtaining a urine specimen can be useful for several reasons. It can be tested for the presence of alcohol, other substances, or toxins. Additionally, it can provide information about the client's overall health and kidney function.

Choice E Reason:

Monitoring the client’s vital signs frequently is crucial. Alcohol intoxication can lead to vital sign abnormalities such as hypotension, tachycardia, or respiratory depression. Normal ranges for vital signs vary but generally include a blood pressure of 90/60 mmHg to 120/80 mmHg, a heart rate of 60 to 100 beats per minute, and a respiratory rate of 12 to 20 breaths per minute.

A. Cardiac monitor B. Blood pressure monitor C. Portable x-ray machine D. Electroencephalogram (EEG) monitor E. Ophthalmoscope

Correct Answer is ["A","B","D"]

Explanation

Choice A reason: A cardiac monitor is essential during ECT to monitor the heart's electrical activity, as the procedure can affect heart rate and rhythm.

Choice B reason: A blood pressure monitor is necessary to track the client's blood pressure throughout the procedure, as ECT can cause fluctuations in blood pressure.

Choice C reason: A portable x-ray machine is not typically required in the setup for ECT.

Choice D reason: An EEG monitor is used during ECT to record the electrical activity of the brain, which is crucial for assessing the seizure activity induced by the treatment.

Choice E reason: An ophthalmoscope is not used during ECT; it is an instrument for examining the interior structures of the eye.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is creating a plan of care for a client experiencing alcohol intoxication. Which of the following interventions should the nurse plan to include? Select all that apply.

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

Explanation

A nurse is preparing to assist with electroconvulsive therapy (ECT). Which of the following pieces of equipment should the nurse set up in the room prior to the treatment? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

The nurse should frequently assess a client with a depressive disorder for lethality risk related to suicidal ideation. Which questions should the nurse include? (Select all that apply.)

A client is seeking relief for undiagnosed pain. There is no history of significant physical illness or injury. The history reveals that the client was laid off 4 months ago from a job. Which statement made by the client would most strongly suggest a somatoform disorder?

The nurse is providing a high-school prevention program for adolescents and parents about eating disorders. Which important preventative measures will the nurse educate the group regarding? (Select all that apply.)

The nurse is talking with a client who grew up in a home where both parents were alcoholics. Which behaviors does the nurse identify when assessing this client that correlate with this home life? Select all that apply.

The nurse is providing education to a client regarding a new prescription for lithium carbonate. Which statement by the client indicates the need for additional education?

A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? Select all that apply.

A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?