Nokea
A client with a panic disorder has a new prescription for Xanax (alprazolam). In teaching the client about the drug's actions and side effects, which of the following should the nurse emphasize?
- A. Short-term relief can be expected
- B. The medication acts as a stimulant
- C. Dosage will be increased as tolerated
Correct Answer: A
Rationale: Short-term relief can be expected. Xanax is a short-acting benzodiazepine useful in controlling panic symptoms quickly.
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The nurse prepares to administer medications to a client. Which of the following client data are acceptable for use as client identifiers? Select all that apply.
- A. Date of birth
- B. First and last name
- C. Health care provider
- D. Medical record number
- E. Room number
Correct Answer: A, B, D
Rationale: Date of birth (A), first and last name (B), and medical record number (D) are reliable identifiers. Health care provider (C) and room number (E) are not specific to the client.
The nurse enters an infant's room and observes that the infant is responsive but is choking and turning blue. Which of the following actions should the nurse take?
- A. Initiate CPR
- B. Perform abdominal thrusts.
- C. Initiate back slaps and chest thrusts.
- D. Perform a blind sweep of the infant's mouth.
Correct Answer: C
Rationale: Back slaps and chest thrusts (C) are the appropriate intervention for a choking infant. CPR (A) is for cardiac arrest, abdominal thrusts (B) are for older children, and blind sweeps (D) are dangerous.
The nurse is caring for a client with hyperosmolar hyperglycemic state (HHS). The nurse should recognize which characteristic is most consistent with HHS?
- A. Abdominal pain
- B. Altered level of consciousness
- C. History of type 1 diabetes
- D. Kussmaul respirations
Correct Answer: B
Rationale: Altered consciousness (B) is a hallmark of HHS due to severe hyperglycemia and dehydration. Abdominal pain (A) and Kussmaul respirations (D) are more typical of DKA, and HHS is associated with type 2 diabetes (C).
A woman has recently been diagnosed with multiple sclerosis. Which comment by the client indicates that she understands the nature of the disease process?
- A. I understand that recovery will be slow.'
- B. I am faithfully taking the medicines so the symptoms should disappear soon.'
- C. I will avoid being close to my grandchildren until I have been on medication for several months.'
- D. I bought a pretty cane to help me with balance when I am walking.'
Correct Answer: D
Rationale: Using a cane for balance shows understanding of multiple sclerosis' chronic, progressive nature causing mobility issues, unlike expecting full recovery or avoiding grandchildren.
While planning care for a 2 year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?
- A. Strange bed and surroundings
- B. Separation from parents
- C. Presence of other toddlers
- D. Unfamiliar toys and games
Correct Answer: B
Rationale: Separation from parents. Separation anxiety is the greatest stress for a toddler during hospitalization.