Page 2315 - Saunders Comprehensive Review For NCLEX-RN

3. Address hallucinations therapeutically.
4. Provide stimulation in the environment.

5. Provide reality orientation as appropriate.

6. Maintain NPO (nothing by mouth) status.

819. The nurse determines that the wife of an alcoholic client is benefiting from
attending an Al-Anon group if the nurse hears the wife make which
statement?
1. “I no longer feel that I deserve the beatings my husband inflicts on
me.”
2. “My attendance at the meetings has helped me see that I provoke
my husband’s violence.”
3. “I enjoy attending the meetings because they get me out of the
house and away from my husband.”
4. “I can tolerate my husband’s destructive behaviors now that I
know they are common among alcoholics.”
820. A hospitalized client with a history of alcohol misuse tells the nurse, “I am
leaving now. I have to go. I don’t want any more treatment. I have things
that I have to do right away.” The client has not been discharged and is
scheduled for an important diagnostic test to be performed in 1 hour. After
the nurse discusses the client’s concerns with the client, the client dresses and
begins to walk out of the hospital room. What action should the nurse take?
1. Call the nursing supervisor.
2. Call security to block all exit areas.
3. Restrain the client until the primary health care provider (PHCP)
can be reached.
4. Tell the client that the client cannot return to this hospital again if
the client leaves now.
821. The nurse is preparing to perform an admission assessment on a client with a
diagnosis of bulimia nervosa. Which assessment findings should the nurse
expect to note? Select all that apply.
1. Dental decay

2. Moist, oily skin

3. Loss of tooth enamel
4. Electrolyte imbalances

5. Body weight well below ideal range

822. The nurse is caring for a female client who was admitted to the mental health
unit recently for anorexia nervosa. The nurse enters the client’s room and
notes that the client is engaged in rigorous push-ups. Which nursing action is
most appropriate?
1. Interrupt the client and weigh her immediately.
2. Interrupt the client and offer to take her for a walk.
3. Allow the client to complete her exercise program.
4. Tell the client that she is not allowed to exercise rigorously.

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