An adolescent client is admitted to the postoperative unit following open reduction of a fractured femur which occurred when the client fell down the stairs at a party. The nurse notices needle marks on the client's arms. Which assessment findings should the nurse document related to suspected narcotic withdrawal?

Vomiting, seizures, and loss of consciousness.

Hypotension, shallow respirations, and dilated pupils.

Agitation, sweating, and abdominal cramps.

Depression, fatigue, and dizziness.

Answer and Explanation

The Correct Answer is C

Choice A reason: Vomiting may occur in narcotic withdrawal, but seizures and loss of consciousness are more characteristic of severe withdrawal from other substances like alcohol or benzodiazepines. Narcotic withdrawal typically presents with agitation, sweating, and gastrointestinal symptoms, not primarily neurological collapse, making this less accurate for documenting suspected opioid withdrawal in this adolescent.

Choice B reason: Hypotension and shallow respirations are not typical of narcotic withdrawal; they suggest overdose or other conditions. Dilated pupils occur in withdrawal, but agitation and sweating are more prominent. This combination does not fully capture the autonomic and gastrointestinal symptoms of opioid withdrawal, making it incorrect for documentation.

Choice C reason: Agitation, sweating, and abdominal cramps are hallmark signs of narcotic withdrawal, reflecting autonomic hyperactivity and gastrointestinal distress due to opioid cessation. These symptoms align with the clinical presentation of opioid withdrawal in an adolescent with needle marks, supported by addiction medicine evidence, making this the best choice for documentation.

Choice D reason: Depression, fatigue, and dizziness may occur in later withdrawal phases but are less specific than agitation, sweating, and cramps, which are acute and prominent in early narcotic withdrawal. These symptoms are too vague to capture the immediate autonomic response, making this incorrect for documenting suspected opioid withdrawal.

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Correct Answer is A

Explanation

Choice A reason: A mental status examination (MSE) assesses cognition, mood, and thought processes, providing critical data on distractibility and concentration in a short timeframe. This guides the treatment plan for a client with these symptoms, aligning with psychiatric assessment protocols, making it the most important initial assessment.

Choice B reason: Substance use history is relevant but less urgent than an MSE, which directly evaluates current cognitive and emotional state. In 15 minutes, MSE provides immediate data for treatment planning, making substance history secondary and incorrect for the most critical initial assessment.

Choice C reason: Medication compliance informs treatment but does not address the client’s current distractibility and concentration issues as directly as an MSE. The MSE offers real-time insight into symptoms, guiding the plan, making compliance less urgent and incorrect for the primary assessment in this timeframe.

Choice D reason: Motivation for treatment is important but secondary to understanding the client’s current mental state via MSE, which informs immediate interventions for distractibility. Limited time prioritizes objective assessment, making motivation less critical and incorrect for the most important initial treatment planning step.

A. Invite for a walk when client's energy is high. B. Provide television programs with suspense to keep attention engaged. C. Give concise and firm directions for hygiene and dressing. D. Engage the client in competitive activities. E. Assign the client to a single room.

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

Explanation

Choice A reason: Inviting the client for a walk channels high energy during mania into a safe, physical activity, reducing agitation and inappropriate behaviors. This intervention aligns with bipolar disorder management by redirecting energy constructively, supported by psychiatric nursing evidence, making it appropriate for the care plan.

Choice B reason: Suspenseful television programs may overstimulate a manic client, increasing agitation and inappropriate behaviors. Calming, structured interventions like walking or clear directions are more effective. This choice risks escalating symptoms, making it incorrect for managing a client with bipolar disorder’s manic behaviors.

Choice C reason: Concise, firm directions for hygiene and dressing provide structure, helping the manic client focus on essential tasks despite distractibility. This reduces inappropriate behaviors by setting clear expectations, aligning with therapeutic strategies for mania, making it a key intervention for the bipolar care plan.

Choice D reason: Competitive activities may escalate agitation and impulsivity in a manic client, worsening behaviors like sexual comments. Non-competitive, calming interventions like walking are safer. This choice is inappropriate, as it risks increasing mania-related disruption, making it incorrect for the care plan.

Choice E reason: Assigning a single room reduces stimuli and potential conflicts with others, providing a calmer environment for a manic client. This supports safety and minimizes inappropriate interactions, aligning with inpatient psychiatric care principles for bipolar disorder, making it an appropriate intervention for the care plan.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is planning the care for a client who is hospitalized with a bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? (Select all that apply)

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

Explanation

A client with a major depressive disorder is admitted to the inpatient psychiatric unit. Which intervention should the nurse use to demonstrate support of the client?

The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse document?

The nurse is performing the admission assessment for a client with schizophrenia in an acute care inpatient facility. The nurse should identify which observed behavior is characteristic of schizophrenia?

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease related?

A client with bipolar disorder tells the nurse about the need to make some deals to improve a retirement savings. Based on this information, which client outcome should the nurse include in the care?

An adult female client with bipolar disorder is seen in the outpatient psychiatric clinic and tells the nurse that she is thinking of harming her sister. Which action is most important for the nurse to take?

The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram. Which information should the client provide to acknowledge understanding?

A client at the mental health center reports difficulty concentrating at work, feeling very tired during the day, and sleeping 4 to 5 hours at night. To further assess for depression, which question is most important for the nurse to ask?