1. A nurse is collecting data from a client who is experiencing
alcohol withdrawal. Which of the following manifestations should
the nurse expect?
Answer: Diaphoresis
The nurse should expect a client who is experiencing alcohol
withdrawal to experience diaphoresis, or increased sweating.
2. A nurse in a long-term care center is caring for an adult client
who has Alzheimer's disease and whose partner died several years
ago. The client appears upset and asks the nurse when his partner
will visit again. The nurse states, "It seems like you are feeling
lonely. Let's take a walk outsideand talk." Which of the following
communication strategies is the nurse using?
Answer: Validation therapy
The nurse is using validation therapy as a strategy to communicate
with the client. This strategy validates the client's feelings and
emotions, even when theydon't coincide with reality. The nurse
should also attempt to integrate redirectiontechniques without the
client realizing he is being redirected.
3. A nurse is reinforcing teaching with a client who has
schizophrenia and a new prescription for chlorpromazine. Which of
the following statements should the nurse include in the teaching?
Answer: "The voices you have been hearingshould decrease"
The nurse should instruct the client that hallucinations and agitated
behavior, whichare positive symptoms of schizophrenia, are targeted
by conventional antipsychotic agents, such as chlorpromazine.
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