A nurse is reviewing the medical records of a group of clients. For which of the following clients should the nurse implement seizure precautions?

A client who is experiencing withdrawal from oxycodone.

A client who is experiencing withdrawal from diazepam

A client who has a low lithium level

A client who has a low imipramine level

Answer and Explanation

The Correct Answer is B

A. A client who is experiencing withdrawal from oxycodone: While withdrawal from opioids like oxycodone can cause various symptoms, including agitation, anxiety, and muscle aches, it's not typically associated with an increased risk of seizures.

B. A client who is experiencing withdrawal from diazepam: Withdrawal from benzodiazepines like diazepam can indeed increase the risk of seizures. Abrupt cessation of benzodiazepines after prolonged use can lead to withdrawal symptoms, including seizures. Therefore, seizure precautions would be appropriate for this client.

C. A client who has a low lithium level: Low lithium levels can potentially lead to lithium toxicity, which can cause various symptoms, but seizures are not commonly associated with low lithium levels. However, in severe cases of lithium toxicity, seizures can occur.

D. A client who has a low imipramine level: Imipramine is a tricyclic antidepressant (TCA). Low levels of TCAs are not typically associated with an increased risk of seizures. However, high levels of TCAs can be toxic and may lead to seizures.

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Correct Answer is C

Explanation

a.Spending equal time with clients regardless of their insurance status: This situation relates more to justice, ensuring fairness and equality in client care, rather than fidelity.

b.This scenario represents the principle of veracity, which involves providing truthful and accurate information to clients. It ensures that clients are fully informed and can give informed consent regarding their treatment.

c.Respecting the decision of clients to refuse to participate in group therapy:Fidelityrefers to the duty to be loyal, faithful, and keep promises. It involves maintaining trust and being reliable in our interactions with clients. This situation aligns with fidelity. Respecting a client's decision to refuse treatment, even if it's something the nurse believes would be beneficial, demonstrates fidelity to the client's autonomy and their right to make choices about their care.

d.This situation reflects the principle of beneficence, which involves taking actions to benefit clients, including continuing education to improve client care and nonmaleficence (avoiding harm).

A. “I can hear him crying in the middle of the night.” B. "He spends most of his time locked in his room.” C. “He refuses to go to the movies with his friends.” D. “I noticed several cutting marks on both of his arms.”

Correct Answer is D

Explanation

A. “I can hear him crying in the middle of the night.”: While this statement indicates distress, it does not necessarily indicate an immediate risk of suicide. Crying can be a symptom of various emotional or psychological issues, but it does not provide direct evidence of suicidal intent.

B. "He spends most of his time locked in his room.”: Social withdrawal or isolating oneself from others can be a warning sign of depression or other mental health issues, including suicidal ideation. However, it alone may not indicate imminent risk of suicide.

C. “He refuses to go to the movies with his friends.”: Social withdrawal or a decline in interest in previously enjoyed activities can also be indicators of depression or other mental health concerns. However, like spending time alone, it does not provide direct evidence of suicidal intent.

D. “I noticed several cutting marks on both of his arms.”: This statement is the most concerning and indicates a potential self-harm behavior. Self-harm, such as cutting, can be a significant risk factor for suicide, especially if the behavior escalates or if the individual expresses suicidal thoughts or intentions.

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A nurse is reviewing the medical records of a group of clients. For which of the following clients should the nurse implement seizure precautions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse in a community mental health clinic is discussing ethical concepts of client care with a newly licensed nurse. The charge nurse should use which of the following situations as an example of fidelity?

Correct Answer is C

Explanation

A nurse in a well-child clinic receives a phone call from the parent of an adolescent client. The parent states. "I think my son might try to kill himself." Which of the following statements by the parent is the priority for the nurse to investigate further?

Correct Answer is D

Explanation

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A nurse is using de-escalation techniques with a client who has become verbally aggressive with a staff member. Which of the following actions should the nurse take?

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