The nurse is admitting a client with a dual diagnosis of major depressive disorder and alcohol abuse. What is the primary intervention?

Administer thiamine intramuscular (IM)

Assist the client with personal hygiene needs

Place the client on continuous observation

Explain milieu therapy

Answer and Explanation

The Correct Answer is B

A. Administer thiamine intramuscular (IM) Administering thiamine is important, especially in
clients with alcohol abuse, to prevent or treat potential Wernicke Korsakoff syndrome. However, the primary intervention when admitting a client is addressing immediate physical and psychological needs, such as personal hygiene.

B. Assist the client with personal hygiene needs This is the primary intervention upon admission.
It addresses the client's immediate physical and psychological wellbeing and helps establish a therapeutic rapport.

C. Place the client on continuous observation While observation may be necessary for safety, it is not the primary intervention in this scenario. Addressing personal hygiene needs takes precedence.

D. Explain milieu therapy Milieu therapy is an important aspect of a comprehensive treatment plan, but it is not the primary intervention upon admission. Immediate physical care and safety are the initial priorities.

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Correct Answer is B

Explanation

A) Incorrect. While understanding the reasons behind the suicidal thoughts is important, in this immediate situation, assessing access to means (medications) is crucial.

B) Correct. This question assesses the immediate risk by determining if the friend has access to the means (medications) to carry out the overdose.

C) Incorrect. While substance use is a risk factor, it may not directly address the immediate threat of overdose with pills.

D) Incorrect. While family issues can contribute to emotional distress, the most pressing concern is the immediate risk of overdose.

A. Diaphoresis, piloerection, tremors, irritability, insomnia, nausea, and vomiting. B. Diaphoresis, hypertension, hand tremors, hallucination/illusions, and potential seizures. C. Cravings, depression, fatigue, hypersomnolence, and impaired judgment. D. Heightened sense of self, hallucinations, flashbacks, incoordination, and panic attacks.

Correct Answer is A

Explanation

A) Correct. These symptoms are indicative of opioid withdrawal. Opioid withdrawal symptoms include sweating (diaphoresis), goosebumps (piloerection), tremors, irritability, insomnia, and gastrointestinal symptoms like nausea and vomiting.

B) Incorrect. These symptoms are more indicative of withdrawal from substances like alcohol or benzodiazepines, rather than opioids.

C) Incorrect. These symptoms are not specific to opioid withdrawal and may be seen in various conditions.

D) Incorrect. This cluster of symptoms is not characteristic of opioid withdrawal.

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The nurse is admitting a client with a dual diagnosis of major depressive disorder and alcohol abuse. What is the primary intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adolescent tells the school nurse, "My friend threatened to take an overdose of pills." The nurse talks to the friend who verbalized the suicide threat. What is the most critical question for the nurse to ask?

Correct Answer is B

Explanation

The nurse is caring for a client who is withdrawing from long-term use of opioids. The nurse will monitor using a Clinical Opioid Withdrawal Scale (COWS). Which of the following cluster of symptoms would indicate to the nurse the client was withdrawing from opioids?

Correct Answer is A

Explanation

The nurse is caring for a client with poor self-esteem. What intervention would be important for the nurse to include in the plan of care?

The nurse is admitting a client with a dual diagnosis of major depressive disorder and alcohol abuse. What is the primary intervention?

While caring for a depressed client, a nurse would evaluate the need for suicide precautions under which circumstance?

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A physician has prescribed an antidepressant medication for a 15yearold client. Which statement would be appropriate for inclusion in medication teaching?

What intervention is a priority when the client is experiencing auditory hallucinations?

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