BSN HESI 266 Med Surg Exam (2026/ 2027 Updated Edition) Comprehensive Qs&As|100% Correct| Graded A- Nightingale

BSN HESI 266 Med Surg Exam (2026/ 2027 Updated Edition) Comprehensive Qs&As|100% Correct| Graded A- Nightingale Q. When explaining dietary guidelines to a client with acute glomerulonephritis which instruction should the nurse include in the dietary? ANSWER Restrict sodium intake 3 multiple choice options Q. An older adult client with long-term type 2 DM is seen in the clinic for a routine health assessment. Which assessment would the nurse complete to determine if a patient with type 2 DM is experiencing long-term complications? (SATA) ANSWER Sensation in feet and legs Skin condition of lower extremities Visual acuity Q. NGN - CHEST PAIN: A 57-year-old male client is brought to the ED by EMS with reports of chest pain. Client was mowing his lawn and noticed chest pain presenting as lightness and pressure. Click to highlight the findings that require follow-up. ANSWER Neuro- agitation Cardiovascular-chest pain described as tightness and pressure Respiratory- Rapid and shallow breathing Pain- Reported 7 on a 0-10 scale, tightness and pressure in chest Q. CHEST PAIN: Select which one or both if they are angina or myocardial infarction: ANSWER A. Epigastric distress- MI B. Chest pain radiating down arm- Both MI & Angina C. Pain only relieved by opioids- MI D. Occurring without cause- MI E. Feeling of fear- MI F. Pain relieved by nitroglycerin- Angina Q. CHEST PAIN: Choose the most likely options for the information missing from the statement by selecting from the list of options provided. The nurse determines that the client has ___ as evidenced by St depression on electrocardiogram and normal ____ ANSWER a. new onset angina b. troponin Q. NGN - CHEST PAIN: Drag and drop word choices to complete the sentence. If healthcare providers see a narrowed heart vessel while performing a percutaneous coronary intervention (PIC), they may perform a balloon angioplasty to compress the plaque against the Vessel wall and hold it there with a stent, which will lessen ____and ____ ANSWER a. Vaso b. Pain Q. NGN - CHEST PAIN: Which 2 statements from the client should the nurse recognize as a need for further education: ANSWER a. I will take the nitroglycerin 1 or 2 more times 10 minutes apart if the pain does not get better b. I will chew my nitroglycerin as soon as the pain begins Q. Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with a lens implant ANSWER a. Administer a stool softener Q. The nurse is administering the second unit of whole blood to an older adult client who was admitted yesterday with gastrointestinal (GI bleeding. Which parameters should the nurse monitor that indicate fluid overload? ANSWER Bounding pulse, hypertension, and distended neck veins Q. The nurse is teaching a client with cancer about skincare for the portal site receiving external beam radiation. Which client action about skincare indicates a need for further teaching? ANSWER a. Washes the radiation with antibacterial soap and water Q. The nurse observes that a client with Parkinson's disease (PD) has a mask like face. Which follow up assessment is MOST important for the nurse to implement? ANSWER a. Determine ability to chew and swallow Q. NGN - Amputation: The client is a 48-year-old male with gangrene of the right lower leg which has not been responsive to treatment. A below-the-knee amputation (BKA) of the right lower leg has been performed. The client has a history of peripheral vascular disease and hypertension and has a peacemaker for 2nd-degree Type II heart block. Highlight the assessment findings that require follow-up by the nurse ANSWER Right leg hanging Right leg cool to touch Left leg whole paragraph Q. NGN - Amp: Select the 3 assessment findings that indicate ineffective peripheral tissue perfusion for this client ANSWER a. Capillary refill b. Edema c. Pale skin Q. NGN - Amputation: Drag the word choices to complete the sentence: The client is at risk for ____, ____, and ____. ANSWER a. Infection b. Contractures c. Neuroma Q. NGN - Amputation: Which items should the nurse teach the client? (SATA) ANSWER a. Alternating position c. Therapeutic coping d. Prevention of skin breakdown Q. NGN - Amputation: For each client activity, click to indicate whether the activity shows positive or negative health promotion post amputation due to extensive peripheral vascular disease. ANSWER a. Insures about blood pressure - positive b. Ask questions about self-care - positive c. Avoids looking at residual limb – negative d. Requests nurse to perform wound care – negative e. Turns side to side – positive f. Executes pull-ups on trapeze bar - positive Q. Which client has the highest risk for developing skin cancer? ANSWER a. A 65-year-old fair-skinned client who is a construction worker. Q. When caring for a client with a cervical spinal cord injury, which intervention is the MOST important for the nurse to implement? ANSWER a. Immobilize the head in anatomical alignment Q. A client is to receive progesterone 10 mg IM daily. The medication is labeled "Progesterone 50 mg/mL." How many mL should the nurse administer? ANSWER a. 0.2 Q. A client with a gram-positive bacterial skin infection is receiving daptomycin 500 mg IV every 24 hours. The pharmacy delivers a secondary infusion of 0.9% sodium chloride with daptomycin 500 mg/100mL to be infused in 30 minutes. How many mL/hour should the nurse program the infusion pump? ANSWER 200 Q. NGN - Amputation: A 24-year-old female client presents to the ED with reports of abdominal pain. The client reports she was vacuuming her home approximately 1 hour prior to arrival when she had a sudden onset of abdominal pain... Choose the most likely options for the information missing from the statement(s) by selecting: The nurse recognizes that the client has ____ as evidenced by ______ and ______ ANSWER a. appendicitis b. CT scan results, c. WBC Q. A client with edema receives a prescription for a one-time dose of furosemide 20 mg IV. The medication is available in a 10 mg/mL vial. How many mL should the nurse administer? ANSWER 2 Q. A client arrives to the ED following a motor vehicle collision. The nurse observes the client experiencing increasing dyspnea and notes absent breath sounds on the left side. Which procedure should the nurse prepare for the client? ANSWER a. chest tube insertion Q. The nurse plans to provide diet instructions to a client who was recently diagnosed with diverticulosis. Which dietary medication should the nurse include in the teaching plan? ANSWER a. Increase intake of insoluble fiber Q. The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with type 2 DM. Which outcomes should the nurse include in the plan of care for this client? ANSWER a. The client’s hemoglobin A1C will be less than 7% in 3 months Q. A client with a new diagnosis of glaucoma is concerned about going blind. To help prevent blindness due to glaucoma, the nurse should instruct the client to implement which actions? (SATA) ANSWER a. Meticulously follow a regimen for administering prescribed eye drops. b. Schedule regular appointments to measure eye pressure. c. Report any changes in vision perception immediately. Q. A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions? ANSWER a. Monitor urinary stream for decrease in output. One hour after abdominal surgery, a client in the post-anesthesia care unit (PACU) has a BP of 136/80. Fifteen minutes later, it is 114/72. Which actions should the nurse take FIRST? a. Check the abdominal surgical dressing. Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome? a. Central type obesity, with thin extremities. A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation extends above the ankle area. The client receives prescriptions for colchicine and indomethacin. Which instructions should the nurse include in the discharge teaching? a. Return for periodic liver function studies. NGN - Amputation: The client is a 68-year-old female with a history of type 2 DM, hypertension, coronary artery disease, and recently diagnosed with ERSD. She has been on hemodialysis three times a week for the last month. She presented to the ED with fatigue, generalized weakness, muscle cramps, tingling sensation in arms and legs, and lightheadedness following 3 days of illness during which her husband reported she had bouts of nausea and had a poor appetite and was not able to go for her scheduled dialysis. a. Call the healthcare provider to notify changes in vital signs b. Perform a 12-lead ECG STAT c. Administer calcium gluconate STAT e. Clarify order of lisinopril with the healthcare provider f. Draw potassium level STAT i. Check blood glucose level STAT j. Perform a focus cardiovascular assessment A male client who had abdominal surgery 5 days ago, and hospitalized because of a surgical wound infection, tells the nurse that he feels like his insides just spilled out when he coughed. What action should the nurse take first? A. Visualize the abdominal incision A client tells the clinic nurse about experiencing burining on urination, and assessment reveals that the client had sexual intercourse four days ago with a person who was a casual acquaintance. Which action should the nurse implement? A. Obtain a specimen of urethral drainage for culture. A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the health care provider? A. low back pain and hypotension Two days after a nephrectomy, the client reports abdominal pressure and nausea. Which assessment should the nurse implement? a. Auscultate bowel sounds A client with orthopnea expresses concern about the ability to "get enough air" during a scheduled thoracentesis. On which information should the nurse's response be based? C. The procedure is performed with the client in an upright position. Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers? A. Oatmeal raisin and fruit with skin The nurse is caring for a client with a burn that is severely edematous with a wound bed that is brown and yellow in appearance. The client expresses feeling no pain. Which classification of burn depth should the nurse document? D. Full-thickness A male client is admitted to the emergency department while vomiting dark brown, foul-smelling emesis. He reports having a surgical repair of a recurrent inguinal hernia a week ago and is troubled by intense abdominal pain. After finding that his bowel sounds are hyperactive, which prescription should the nurse implement first? A. Insert a nasogastric tube (NGT) and attach to low intermittent suction (LIS). While performing a neurovascular assessment distal to a client's fracture site, the nurse determines that the client's pulse is present, regular and full. Which nursing action should be taken next? A. Document the NV assessment as normal A 35-year-old woman, who works as a legal secretary, presents to the outpatient clinic for assessment of consistent pain in her hands. The client reports that the pain is the same in both hands and wrists but is worse upon waking. The pain and stiffness have been going on for the past 3 months. She shares that she thinks she has arthritis because her mother and grandmother both have arthritis. a. Potential Conditions: Rheumatoid arthritis b. Actions to take: Consult dietician for nutrition and weight loss, educate on disease process c. Parameters to monitor: Pain & physical mobility A client with chronic syndrome of inappropriate antidiuretic hormone (SIADH) reports to the nurse of being constantly thirsty. WHich action should the nurse take? a. Encourage the client to use hard candy frequently to help relieve thirst A client with eczema is applying 10% urea cream onto the affected skin areas. Which finding reflects the expected therapeutic response? B. Hydration of affected dry skin areas. The parent of an adolescent tells the clinic nurse, "My child has athlete's feet. I have been applying triple antibiotic ointment for two days, but there has been no improvement." Which instruction should the nurse provide? B. Stop using the ointment and encourage complete drying of feet and wearing clean socks. Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. Which instruction is most important for the nurse to include in the discharge teaching plan? C. Drink 3 liters of water each day. Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires the most immediate action by the nurse? a. Preoperative serum potassium level is 2.8mEq /L A client with a history of asthma reports having episodes of bronchoconstriction and increased mucus production while exercising. Which action should the nurse implement? A. Determine if the client is using an inhaler before exercising. The nurse is developing a plan of care for a client with type 2 diabetes mellitus (DM). When providing teaching on lowering blood glucose levels and increasing serum high- density lipoprotein (HDL) levels, which instruction should the nurse include? a. Regular exercise with medical approval The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for? C. Lumbar puncture. The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this medical diagnosis? C. Upper mid abdominal pain is described as gnawing and burning. NGN: A 68-year-old male client is 24 hours postoperative from left hip surgery on the orthopedic floor. The surgery was due to a fall. No surgical complications were noted. Total right knee surgery was done due to osteoarthritis 18 months ago, and the client has a significant history of tobacco use, smoking half a pack per day for 25 years. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing. a.Potential Condition: surgical complication of DVT b. Actions to Take: anticoagulation therapy STAT & Early ambulation c. Parameters to Monitor: Development of pulmonary embolus & CBC, platelet count, coagulation studies, and stool for occult blood Which nursing problem has the highest priority when planning care for a client with osteomalacia? a. Risk for injury An adult woman with Grave's disease is admitted with severe dehydration and malnutrition. She is currently restless and refusing to eat. Which action is most important for the nurse to implement? D. Maintain a patent intravenous site. The nurse is teaching a client how to collect a sputum specimen. Which steps should the nurse instruct the client to follow when collecting a sputum? D. Breathe deeply, followed by coughing up the sputum. A client with pernicious anemia takes supplemental folate and self administer monthly vitamin B12 injections. The client reports feeling increasingly fatigued. Which laboratory value should the nurse review? a. Complete blood count An older adult client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern? A. Demonstrate the use of visual scanning during meals to the client and family. An older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? a. Assist client to an upright position A client with cholelisthiasis is admitted with jaundice due to obstruction to the common bile duct. Which finding is most important for the nurse to report to the healthcare provider? D. Distended, hard, rigid abdomen A client with newly diagnosed Chron's disease asks the nurse about dietary restrictions. How should the nurse respond? Describe the use of an elimination diet to find trigger foods 3 multiple choice options Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy? Monitor the clients IV site hourly during the treatment 3 multiple choice options while caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound before reporting this finding to the healthcare provider, the nurse should review which of the lab values? White blood cell (WBC) 3 multiple choice options While assessing a client with degenerative joint disease, the nurse observes heberden's nods, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take? discuss approaches to chronic pain control with the client 3 multiple choice options A client who has developed acute kidney injury due to aminoglycoside antibiotics has moved from the oliguric phases to the diuretics phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor? Hypovolemia and ecg changes 3 multiple choice options A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickening mucous and the inability to walk up a flight of stairs without experiencing breathlessness. What action is most important for the nurse to instruct the client about self care? Increase the daily intake of oral fluids to liquify secretions 2 multiple choice options An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take? continue to monitor the fingers until color returns to normal 3 multiple choice options A client who has a history of hyperthyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse? further decline in LOC 3 multiple choice options A client with Addison's disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value? glucose 3 multiple choice options A client with pheochromocytoma reports the onset of a severe headache. The nurse observes that the client is very diaphoretic. Which assessment data should the nurse obtain next? blood pressure 3 multiple choice options the nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis? hypoalbuminemia that results in a decreased colloidal oncotic pressure The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving psoralen and ultraviolet A light (puva) treatment. Which assessment findings indicates that the client has been overexposed to the treatment? tenderness upon palpation and generalized erythema 3 multiple choice options An adult client who had a gastric bypass surgery 2 weeks ago, is admitted with possible anastomosis leakage. The client's abdomen is tender to touch and the vital signs are temp 101, HR 130 BP,. rr 26, BP 100/50. Which intervention is most important for the nurse to include in the client's plan of care? strict IV replacement 3 multiple choice options A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instructions should the nurse provide? wearing gloves when handling cold items guars against painful spasms 3 multiple choice options the nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi? eats a vegetarian diet with cheese 2 to 3 times a day 3 multiple choice options A client is diagnosed with chronic kidney disease and needs to bein dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis? Crohn's disease with colectomy A client presents to the ED reporting chest pain that is radiating to the left arm, shortness of breath. and diaphoresis. Which medication should the nurse anticipate being prescribed by the healthcare provider? Morphine 3 multiple choice options An adult who was recently diagnosed with glaucoma tells the nurse, "It feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurses to provide this client? Maintain prescribed eye drop regimen 3 multiple choice options Which information should the nurse include on the teaching plan of a client diagnosed with gastroesophageal reflux disease minimize symptoms by wearing loose, comfortable clothing 3 multiple choice options a client arrives to the ED reporting intermittent fever and night sweats for the past 3 weeks and has developed a productive cough containing small amounts of blood. Which intervention should the nurse prioritize? move into airborne isolation 3 multiple choice options the nurse is caring for a client with chronic pancreatitis who reports persistent gnawing and abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain? eating patterns of dietary intake 3 multiple choice options an older client who is agitated, dyspneic, orthopneic, and using accessory muscles to breathe is admitted for further treatment. Initial assessment includes a HR 128 bpm and irregular, respirations 38, blood pressure 168/100, wheezes, and crackles in all lung fields. An hour after the administration of furosemide 60 mg IV, which assessments should the nurse obtain to determine the client's response to treatment? SATA Oxygen sat lung sounds urinary output A client is accompanied to the ED by a police officer who found him standing on a bridge threatening to jump. The client planned to jump off the bridge because significant other moved out of their shared home & the client lost their job as a chef several days ago. The client has a strong odor of alcohol on their breath but reports drinking only 4 beers in the last 12 hours. The client denies using medications/illegal drugs within past 72 hours. The client is known to the staff because of previous admissions related to alcohol abuse. The client is angry/uncooperative & the nurses will not allow client to leave. The client states that they have felt sad for several weeks which is the reason for drinking alcohol. The client reports sleeping 5-6 hours a night & states their appetite is poor, resulting in significant weight loss over the past month. Physical health problems include history of compromised liver function. "Have you ever thought that you should cut down on your drinking?" This is the first question in the questionnaire. In CAGE, C stands for cut down. Alcoholic may realize they consume too much alcohol, which leads to uninhibited and embarrassing behavior. When sober, an alcoholic may make a pledge to reduce consumption. RATIONALE FOR INCORRECT: "Have people annoyed you by criticizing your drinking?" This is the second question of the questionnaire. In CAGE, A stands for annoyed. Often the behaviors of alcoholics, especially when inebriated, are annoying to family and friends. Frequently the alcoholic is unaware of the behavior and is angered when family and/or friends complain. "Have you ever felt bad or guilty about your drinking?" This is the third question of the questionnaire. In CAGE, G stands for guilty. When sober, alcoholics often experience feelings of embarrassment and guilt about behavior that occurred while intoxicated. "Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?" This is the fourth question in the questionnaire. In CAGE, E stands for eye-opener. Eye-opener is a term used to describe the need to drink alcohol as soon as waking up to ward off or try to eliminate a hangover. It is a serious indication of overconsumption. What is the first question that the nurse should ask? "Have people annoyed you by criticizing your drinking?" "Have you ever felt bad or guilty about your drinking?" "Have you ever thought that you should cut down on your drinking?" "Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?" Further assess the client's drinking behaviors. The CAGE questionnaire is only a screening tool used to identify alcohol abuse; therefore, further assessment is needed to make a diagnosis of alcoholism. RATIONALE FOR INCORRECT: The CAGE questionnaire is a screening tool that is used to identify individuals who may be abusing alcohol. The nurse needs more information to determine if the client has an alcohol addiction. A breathalyzer is a screening tool used to determine recent alcohol use. The CAGE questionnaire is used as a screening tool for alcohol abuse. The nurse needs more information to determine if the client has an alcohol addiction. A urine drug screen is a tool for alcohol or drug use. While this screening may become necessary to determine if the client is using other drugs, the nurse needs more information to determine if the client has an alcohol addiction. The client answers "yes" to two of the four questions on the CAGE questionnaire. If it is determined the client is dependent on alcohol, which information should the nurse obtain in order to predict the onset of withdrawal symptoms? The frequency with which the client drinks alcohol. The last time the client consumed an alcoholic beverage. The quantity of alcohol the client usually drinks. Past withdrawal symptoms the client has experienced. The last time the client consumed an alcoholic beverage. This can help the nurse predict the onset of withdrawal symptoms, which can begin as early as 6 to 8 hours after alcohol use. RATIONALE FOR INCORRECT: With increased frequency of alcohol consumption, tolerance is likely to develop, resulting in withdrawal symptoms. By itself, frequency of drinking is not a good predictor of the onset of withdrawal. The quantity of alcohol the client usually drinks will not help the nurse predict the onset of withdrawal symptoms. The client is likely to use denial, so a good rule of thumb is to double the amount of reported intake. The client's previous withdrawal experiences will not predict the onset of the current withdrawal symptoms. If the client has experienced withdrawal in the past, it can help identify how the client will experience current symptoms. The nurse completes the assessment and reports the findings to the healthcare provider (HCP). The HCP talks with the client who is admitted to the crisis unit with an admitting diagnosis of alcohol dependency and depression with suicidal ideation. Which data supports the need for admission to the hospital? Drinking alcohol with potential withdrawal Ineffective denail about severity of problem Elevated vital signs and liver disease Thoughts of wanting to jump off a bridge Thoughts of wanting to jump off a bridge. The client is at risk for self-harm, which is a priority problem that requires hospitalization. RATIONALE FOR INCORRECT: Drinking alcohol and potential withdrawal do not justify the need for hospitalization unless medical complications are anticipated. Ineffective denial is a common defense mechanism that often occurs with substance use and does not warrant hospitalization. Elevated vital signs and liver disease do not support the need for immediate hospitalization unless there are acute medical complications. Section 2 Admission to the Crisis UnitWhen the client is admitted to the crisis unit, the nurse understands it is best to maintain a quiet, calm environment to help the client relax and decrease nervous system irritability. The nurse assigns a room and searches the client's belongings. Which items can the nurse allow the client to keep in the room? (Select all that apply.) Select all that apply Tennis shoes without laces. Aftershave lotion. Electronic book reader. An electronic cigarette. A personal photo. Tennis shoes without laces. Tennis shoes without laces do not typically pose a threat. Electronic book reader. The client may keep an electronic book reader, but it cannot connect to the internet. The client must keep the battery's charging cord at the nurse's desk and the staff will charge the battery when needed. A personal photo. Personal photos do not pose a threat and may help the client feel more comfortable in the environment. RATIONALE FOR INCORRECT: Aftershave lotion contains alcohol, and this is contraindicated for the client. All cigarettes, including e-cigarettes, must be kept at the nurse's desk to ensure that the client doesn't try to smoke in the hospital. Which priority nursing problem should be addressed within 72 hours of admission? (Select all that apply.) Select all that apply Ineffective denial. Risk for injury. Ineffective coping. Altered nutrition. Risk for withdrawal. Risk for injury. Risk for injury related to the client's thoughts of wanting to jump off a bridge is a priority nursing problem and the rationale for admission to the crisis unit. Altered nutrition. A client with alcohol dependency drinks alcohol instead of eating nourishing food, causing malabsorption of essential vitamins. Deficiency and malabsorption of vitamin B can cause Wernicke's disease, a severe problem with decreased cognitive functioning. Risk for withdrawal. Alcohol withdrawal can occur as early as 4 to 6 hours after the client's last drink. RATIONALE FOR INCORRECT: The client's denial is a defense mechanism that reduces anxiety. According to Maslow's hierarchy, it is not a priority. Ineffective coping is a problem related to inadequate coping skills, but another nursing problem should be addressed first. Routine admission prescrptions include regular diet, nutrition consultation, vital signs every 4 hours, CBC with differential, urinalysis, and urine drug screen. The healthcare provider also prescribes acetaminophen 325 mg by mouth (PO) every 6 hours as needed (PRN) for pain, fever, or headache. Which routine admission prescriptions should the nurse question? A regular diet. Vital signs every 4 hours. Acetaminophen as needed. Urinalysis and urine drug screen. Acetaminophen as needed. The client is suspected of having liver problems due to alcohol. Acetaminophen can be toxic to the liver, especially in combination with alcohol. The nurse should question this prescription as it is contraindicated for the client. RATIONALE FOR INCORRECT: A regular diet is appropriate for the client. Vital signs every 4 hours is routine and applicable. This is a routine admission prescription and is appropriate for the client. Which lab results indicate to the nurse the client likely has liver disease? Hyperkalemia. Increased aspartate aminotransferase (AST). Reduced alkaline phosphatase. Decreased blood urea nitrogen (BUN). Increased aspartate aminotransferase (AST). Liver disease can cause a change in tissues of the liver and result in an elevation of AST. The amount of AST in the blood is directly related to the number of damaged cells. RATIONALE FOR INCORRECT: Hypokalemia, rather than hyperkalemia, occurs in alcoholism due to urinary excretion of potassium. Alkaline phosphatase is elevated, not reduced, in liver disease. The blood level of alkaline phosphatase rises when excretion is impaired as a result of obstruction in the biliary tract. Increased, not decreased, BUN occurs with alcoholism. Section 3 Alcohol DetoxificationThe nurse follows the alcohol detoxification protocol. Which goal is most important for alcohol detoxification? Discontinued drug-seeking behaviors. Physiological stabilization. Normal liver function test results. Enhanced coping skills. Physiological stabilization. The acute management goals of alcohol detoxification begin with stabilizing the client physically and maintaining normal vital signs. RATIONALE FOR INCORRECT: The judicious use of prescribed medications enables the client to safely detox, so it is not necessary to eliminate the use of all medications at this point in the client's treatment. Liver function tests can be ordered by the healthcare provider to monitor for the extent of liver damage, but it is not the most important goal for the first 72 hours of alcohol detoxification. Enhancing coping skills can only occur when the client is able to focus on the psychological work related to addiction, lifestyle changes, and alternatives for coping. This is a later goal in the plan of care. Which assessment is most important for safe alcohol detoxification? Vital signs at least every 4 hours. Type of alcohol ingested. Amount and last use of alcohol. History of delirium tremens (DTs). Vital signs at least every 4 hours. Vital signs are an objective measure of alcohol withdrawal, especially when the diastolic blood pressure, pulse, and temperature are near or above 100. RATIONALE FOR INCORRECT: The type of alcohol ingested will be assessed on admission, but is not the priority during alcohol detoxification. Assessing the amount and last use of alcohol is part of the admission assessment and will help determine the onset of withdrawal symptoms. Assessing history of DTs is part of the admission assessment and will help determine the likelihood of DTs during detoxification. When should the nurse begin assessing for withdrawal? Within 8 to 12 hours of the client's last drink. 12 hours after admission. As blood pressure becomes elevated. When hand tremors are visible. Within 8 to 12 hours of the client's last drink. Early alcohol withdrawal can begin as early as 4 to 6 hours after substance use is stopped. RATIONALE FOR INCORRECT: Alcohol withdrawal can begin in 12 hours, but the nurse should be prepared to begin assessment sooner than 12 hours. The client may have other symptoms of withdrawal before blood pressure becomes elevated. The client may have other symptoms of withdrawal before hand tremors are visible. Which should the nurse anticipate if the client experiences symptoms of early withdrawal from alcohol? Mild disorientation and confusion. Tactile or auditory hallucinations. Tremors, nausea, and vomiting. Sleeping more than usual. Tremors, nausea, and vomiting. In addition to tremors, nausea, and vomiting, other symptoms of early withdrawal include elevated vital signs, diaphoresis, insomnia, combativeness, agitation, and decreased concentration. RATIONALE FOR INCORRECT: Disorientation and confusion occur with severe withdrawal. Hallucinations generally occur after early withdrawal. Clients who experience early withdrawal have insomnia. Section 4 Management of Alcohol WithdrawalThe Clinical Institute Withdrawal Assessment-Alcohol, Revised (CIWA-AR), is a 10-item scale that monitors a client's response to treatment. It is a tool that determines the need for medication and can be used for management of alcohol withdrawal. Without effective management of alcohol withdrawal, the client can experience seizures or delirium, which is characterized by the impairment of memory, attention, thinking, perception, and orientation. What mechanism of action accounts for symptoms of alcohol withdrawal delirium? Increased dopamine. Increased GABA. Decreased norepinephrine. Increased serotonin. Increased dopamine. Alcohol intake represses gamma-aminobutyric acid (GABA), which inhibits dopamine. When alcohol is eliminated, dopamine rebounds above the normal level, resulting in excitation and alterations in thought, perception, and orientation. RATIONALE FOR INCORRECT: Increased GABA will have a calming effect. Decreased norepinephrine results in fatigue, the inability to experience pleasure, and feeling "blah." Increased serotonin results in feelings of happiness and boosts feelings of self-esteem and self-confidence. Eight hours after admission, a new nurse is assigned to care for the client. After receiving report, the nurse reviews the recent information in the chart.Vital Signs Blood pressure 146/98 mmHg Heart rate 100 beats/min Respirations 22 breaths/min Temperature 99.8° F (37.7° C) Laboratory Data AST: 80 U/L (1.34 µkat/L) ALT: 96 U/L (1.60 µkat/L) Sodium: 145 mEq/L (145 mmol/L) Potassium: 3.6 mEq/L (3.6 mmol/L) Prescriptions 1. Perform withdrawal assessment every 4 hours. 2. Lorazepam 2 mg PO every 6 hours prn per alcohol withdrawal protocol. 3. Continue suicide precautions. The nurse performs the withdrawal assessment and observes moderate tremors. The client reports nausea. Which interventions should the nurse implement? (Select all that apply.) Select all that apply Ask the primary HCP if the client can receive a prescription for chlordiazepoxide. Administer lorazepam 2 mg PO. Reassess vital signs in 2 hours. Place the client on a continuous pulse oximetry monitor. Provide an antiemetic. Administer lorazepam 2 mg PO. The client has compromised liver function; therefore, a short-acting benzodiazepine such as lorazepam is best to give for withdrawal because it does not have active metabolites that can affect a diseased liver. Lorazepam is often given if a client has known liver disease or decreased liver function. Reassess vital signs in 2 hours. The nurse can reassess the vital signs to monitor for changes. Provide an antiemetic. The client reports feeling nauseous, so administering an antiemetic is advised. RATIONALE FOR INCORRECT: The client's liver function test results are high. Normal AST is between 5 to 40 U/L (0.08 to 0.67 ukat/L), and normal ALT is between 7 to 56 units/L (0.12 to 0.94 ukat/L). Since the client has a compromised liver function, a benzodiazepine such as chlordiazepoxide with active metabolites should not be given because it can adversely affect a diseased liver. The client's respirations are within normal range and there is no evidence of respiratory compromise. The nurse gives the client a benzodiazepine for withdrawal symptoms and an antiemetic for nausea. What is the therapeutic action of benzodiazepines? Potentiate the effects of GABA. Block the reuptake of dopamine. Block the reuptake of serotonin. Activate opioid receptors. Potentiate the effects of GABA. Benzodiazepines potentiate the effects of GABA, which has a calming effect. RATIONALE FOR INCORRECT: Benzodiazepines do not block the reuptake of dopamine. Blocking the reuptake of dopamine prolongs the action of dopamine and causes excitation. Benzodiazepines do not block the reuptake of serotonin. Serotonin increases feelings of happiness, self-esteem, and self-confidence and also helps to decrease impulsive behavior. Benzodiazepines do not activate opioid receptors. On the second day of hospitalization, the nurse prepares to give the client thiamine and a multivitamin. Magnesium chloride is also prescribed to enhance the effectiveness of the thiamine. What is the rationale for giving thiamine (B1) and a multivitamin? Reduce the risk of Wernicke disease. Prevent occurrence of delirium tremens. Lessen alcohol withdrawal symptoms. Help increase the client's appetite. Reduce the risk of Wernicke disease. Vitamin B deficiency is common in clients diagnosed with alcoholism. The small intestine is a major site of alcohol absorption, which interferes with adequate thiamine and all B vitamin absorption. Vitamin B deficiency can cause Wernicke disease. RATIONALE FOR INCORRECT: Thiamine and a multivitamin will not prevent delirium tremens or alcohol withdrawal syndrome. Thiamine and a multivitamin will not lessen alcohol withdrawal symptoms. Increasing the client's appetite is not the rationale for giving thiamine and a multivitamin. Section 5 Ethical-Legal Issues: Adverse Event ReportA mental health technician arrives to help the client take a shower. The technician gathers towels and shower items, then helps the client to the shower. When entering the shower, the client slips and falls to the floor. The technician reports the incident to the nurse. The nurse assesses the client who denies suffering any injuries. The nurse documents the assessment, which includes a full set of vital signs, and then notifies the healthcare provider (HCP). The nurse knows an adverse event report must be completed. The technician helping at the time of the accident needs to complete the report. The nurse should ask the technician to complete the report because the technician witnessed the client's fall. Section 6 Interventions to Maintain AbstinenceAfter 3 days in the crisis stabilization unit, the client exhibits no further withdrawal symptoms. The nurse collaborates with the social worker and the HCP to determine discharge plans. The client wants to return to work as soon as possible. The client describes work as being a trigger for drinking and asks the nurse what can be done to prevent a relapse. Which response by the nurse is accurate? Disulfiram decreases cravings for alcohol. Disulfiram inhibits absorption of alcohol. Disulfiram blocks the effects of endorphins. Disulfiram prevents the client from drinking. Disulfiram inhibits absorption of alcohol. Disulfiram inhibits the absorption of alcohol and raises the level of acetaldehyde, causing a severe reaction when alcohol is ingested. RATIONALE FOR INCORRECT: Disulfiram does not decrease the cravings for alcohol. Medications such as naltrexone decrease cravings during the early stages of abstinence. Disulfiram does not block the effects of endorphins. Disulfiram cannot prevent someone who is determined to drink from drinking, but it can curtail impulsive drinking. The client should not drink until 14 days after disulfiram has been discontinued. Which nursing intervention is most important to implement before disulfiram therapy? Obtain the client's written consent to comply with facility protocol. Ensure that the client will not have access to alcohol after discharge from the hospital. Determine the longest period of sobriety and need for abstinence. Help the client identify triggers leading to possible alcohol abuse. Obtain the client's written consent to comply with facility protocol. Informed consent must be obtained to receive disulfiram therapy, or documentation can be noted in the chart that education was given about potential serious complications that can occur if client does not abstain from drinking. RATIONALE FOR INCORRECT: Although the client should abstain from alcohol, his access to alcohol after discharge is out of the nurse's control. There is no need to determine length of sobriety and need for abstinence. The client only needs to be motivated to comply with therapy. This is not the most important intervention, but it can help the client identify better ways of coping with potential stressors. What are the ramifications of drinking alcohol while taking disulfiram? (Select all that apply.) Select all that apply Severe headache. Nausea and vomiting. Hypertension. Chest pain. Hypotension. Severe headache. A severe headache is one of the unpleasant consequences of drinking alcohol while taking disulfiram, an aldehyde dehydrogenase inhibitor. Nausea and vomiting. Nausea and vomiting are unpleasant consequences of drinking alcohol while taking disulfiram, an aldehyde dehydrogenase inhibitor. Chest pain. Chest pain is an unpleasant consequence of drinking alcohol while taking disulfiram, an aldehyde dehydrogenase inhibitor. Hypotension. Hypotension is an unpleasant consequence of drinking alcohol while taking disulfiram, an aldehyde dehydrogenase inhibitor. RATIONALE FOR INCORRECT: Hypertension is not a consequence of taking disulfiram. While the nurse explains the potential consequences of drinking alcohol while taking disulfiram, the nurse also tells the client about household products containing alcohol that should be avoided, including cough medicine and aftershave lotion. Which products are acceptable for the client to use? (Select all that apply.) Select all that apply Ibuprofen. Mouthwash. Hand sanitizer. Petroleum jelly. Nonalcoholic beer. Ibuprofen. Ibuprofen is a nonsteroidal antiinflammatory medication used to treat fever and mild to severe pain. It does not contain alcohol and is safe for the client to use. Petroleum jelly. Petroleum jelly does not contain alcohol, so it is safe for the client to use. RATIONALE FOR INCORRECT: Most mouthwashes contain alcohol and should be avoided by the client. Most hand sanitizers contains alcohol and should be avoided by the client. Any topical items containing alcohol should be avoided. At times, nonalcoholic beer contains a small amount of alcohol and should be avoided by the client. Section 7 Discharge Planning Addiction treatments and interventions for maintenance are generally based on the idea of addiction as a disease, abstinence from all alcoholic substances, participation in a 12-step program like Alcoholics Anonymous (AA), and confrontation of denial and other defense mechanisms. After two weeks of hospitalization, the client has detoxed from alcohol and denies current thoughts of suicide. The nurse knows the client experienced a situational crisis, and the goal is to return to a precrisis level of functioning. Which question should the nurse ask the client in order to determine whether the client is able to return to a precrisis level of functioning? "Do you have a support system and people who can help you?" "How have you successfully handled past crises?" "Why do you always feel so sad?" "What are some of your strengths?" "Do you have a support system and people who can help you?" The nurse must determine if the client has an adequate support system. RATIONALE FOR INCORRECT: "How have you successfully handled past crises?" This question is best for the assessment phase of the crisis to identify coping mechanisms, specifically strengths and previous coping ability. "Why do you always feel so sad?" This is not a therapeutic question that invites insight into the client's level of functioning. "What are some of your strengths?" This question is appropriate for the assessment phase and is the first step of crisis intervention. The nurse collaborates with the treatment team to make plans to discharge the client. Which is the most important consideration for discharge planning? Resources available to the client after discharge. Client's knowledge of the ongoing disease process. Longest period of sobriety and potential for relapse. Participation with Alcoholics Anonymous (AA) for abstinence. Resources available to the client after discharge. The most important consideration is the availability of resources to the client after discharge. These resources can include counseling with significant others, group therapy, and self-help programs like Alcoholics Anonymous. RATIONALE FOR INCORRECT: Knowledge of the disease process can enhance the client's ability to maintain sobriety and stay motivated to change behaviors, but it is not the most important consideration for discharge planning. The longest period of sobriety can provide evidence of past success or failure, but it is not the most important consideration for discharge planning. There are many modalities available to clients for discharge planning, although AA is the most common group. Section 8 Management Considerations: SupervisionThe nurse enters the client's room to assess readiness for teaching related to local 12-step programs and observes that the unlicensed assistive personnel (UAP) is already providing information about local programs. Explain to the UAP, away from the client, that initial client teaching must be performed by the nurse. Initial client teaching requires the expertise of the nurse. RATIONALE FOR INCORRECT: The nurse must complete initial client teaching, so teaching must be repeated and documented as performed by the nurse. The nurse must complete initial client teaching, which requires expertise beyond the level of a UAP. Request that the UAP be assigned to another unit. This is not necessary at this time. Section 9 After the nurse and the UAP discuss initial client teaching, the UAP expresses concern about a visit from the client's spouse that took place earlier in the day. Which behaviors of the client's partner exhibit codependency toward the client? (Select all that apply.) Select all that apply The client's partner states that moving out of their home caused the client to start drinking heavily. The client's partner removed hidden alcohol from the home and is now moving back to keep a close eye on the client. The client's partner brings two new pairs of jeans because the client only had one pair. The client's partner states they would like to have a child together. The client's partner paid all of the bills for the next two months so that the client won't have to worry about finances when discharged. The client's partner states that moving out of their home caused the client to start drinking heavily. Finding excuses for alcohol abuse is considered codependent behavior. The client's partner removed hidden alcohol from the home and is now moving back to keep a close eye on the client. The client's partner feels responsible for the client. Searching for and removing alcohol from the home is further evidence of codependent behavior. The client's partner paid all of the bills for the next two months so that the client won't have to worry about finances when discharged. This shows that the client's partner feels a need to control the finances and assume responsibility for the client's duties. RATIONALE FOR INCORRECT: The client's partner brings two new pairs of jeans because the client only had one pair. This is unrelated to the drinking issue and does not demonstrate codependent behavior. The client's partner states they would like to have a child together. This does not demonstrate codependent tendencies.