The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Alert the assigned staff to closely monitor client and intervene as needed to reduce risk of selfmutilation.

Provide the client time alone in the client's room to reduce external stimulation and promote relaxation.

Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed.

Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm.

Answer and Explanation

The Correct Answer is A

A. The client's increased body tension and pacing indicate escalating distress and potential risk for self-harm. Alerting staff to closely monitor the client and intervene as needed is crucial to ensure the client's safety.
B. Providing time alone in the client's room may be appropriate in some situations but may not address the immediate risk of self-mutilation if the client is experiencing escalating distress. C. Giving firm, consistent expectations about self-mutilating behaviors is important for establishing boundaries, but it may not be sufficient to address the immediate risk of self-harm without additional monitoring and intervention.
D. Completing a thorough room search is important for safety but may not address the immediate risk of self-harm if the client is already exhibiting signs of distress and pacing in the hallway.

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Correct Answer is A

Explanation

A. Cocaine use typically results in stimulation of the central nervous system, leading to increased heart rate, dilated pupils, and heightened alertness.
B. Cocaine use is associated with tachycardia (increased heart rate) rather than bradycardia, and it usually increases respiratory rate rather than causing bradypnea.
C. Hallucinations and delusions are not typical effects of cocaine use; instead, they may occur with substances like hallucinogens or certain psychotic disorders.
D. Lethargy and depression are more commonly associated with the "crash" or comedown phase after cocaine use, rather than immediate effects of ingestion.

A. Folic Acid. B. Haloperidol. C. Trazodone. D. Vitamin B1.

Correct Answer is D

Explanation

A. Folic acid supplementation may be beneficial for some clients, but it is not typically an immediate priority in alcohol detoxification.
B. Haloperidol is an antipsychotic medication and is not typically indicated as an immediate treatment during alcohol detoxification.
C. Trazodone is an antidepressant medication and is not typically indicated as an immediate treatment during alcohol detoxification.
D. Vitamin B1 (thiamine) supplementation is crucial in alcohol detoxification to prevent or treat Wernicke's encephalopathy and Korsakoff's syndrome, which are neurological complications associated with thiamine deficiency commonly seen in individuals with alcohol use disorder.

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The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

A client with a history of alcoholism is admitted for detoxification. Based on treatment protocol, the nurse gives the client a dose of lorazepam 6 mg. Which additional prescription should the nurse administer immediately?

Correct Answer is D

Explanation

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