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1 )Following involvement in a MVC, a middle aged adult client is admitted to the hospital with multiple facial fractures

Nursing

1 )Following involvement in a MVC, a middle aged adult client is admitted to the hospital with multiple facial fractures. The client’s blood alcohol level is high on admission. Which PRN prescription should be administered if the client begins to exhibit signs and symptoms of delirium tremens (DTs)?

A. Prochlorperazine (Compazine) 5 mg IM.

  1. Hydromorphone (Dialuadid) 2 mg IM.
  2. Chlorpromazine (Thorazine) 50 mg IM.
  3. Lorazepam (Ativan) 2 mg IM.

2 . A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, "I am the boss here. I do what I want." Which nursing problem best supports these observations?

  1. Deficient diversional activity related to excess energy level.
  2. Risk for other related violence related to disruptive behavior.
  3. Risk for activity intolerance related to hyperactivity.
  4. Disturbed personal identity related to grandiosity.

3. The RN is preparing medications for a client with bipolar disorder and notices that the client discontinued antipsychotic medication for several days. Which medication should also be discontinued?

 a. Lithium. (Lithotabs)

  1. Benzotropine (Cogentin).
  2. Alprazolam (Xanax).
  3. Magnesium (Milk of Magnesia).

4. The RN on the day shift receive report about a client with depression who was in bed most of the weekend. The RN walks into the client's room in the morning and finds the client in bed. What intervention is best for the RN to implement?

A. Monitor the client's appetite and pattern of sleep.

  1. Assess the client's feelings about the hospital stay.
  2. Assist the client to get out of bed and involved in an activity.
  3. Explain that staff will check on the client every 30 minutes.
  1. A patient who has been on an antidepressant for 2 weeks. What should you watch for?
  2. patient states "I can't get my thoughts together I should really sell my car. It’s not in here. Let's buy a car. What is the patient experiencing? :
  3. A patient won't take oral meds that is going through alcohol withdrawal. The nurse starts giving saline lock per alcohol protocol and thiamine. What do you tell them that it will help with recovery?
  4. A nurse visits a community half way house with one bathroom. The nurse notices urine all over the walls of the bathroom. The toilet is clogged with feces and paper towels.
  5. Older man who recently got divorced and is 2 years sober, and an alcoholic loves God. He loves kids also. What should nurse ask at his initial interaction?
  6. Schizoprenia return to clinic 2 weeks after recieving dose of haldol; important info for the nurse to obtain during this visit –  

 

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