Nokea
A client is prescribed a benzodiazepine as treatment for anxiety. After administration of the drug, the client reports dizziness and lightheadedness. Which nursing diagnosis would the nurse identify as a priority?
- A. Impaired Comfort
- B. Risk for Injury
- C. Ineffective Coping
- D. Deficient Knowledge
Correct Answer: B
Rationale: Dizziness and lightheadedness place the client at risk for falls; therefore, Risk for Injury would be the priority. Impaired Comfort would be appropriate if the client reported problems such as dry mouth or constipation. Ineffective Coping would be appropriate if the client reported continued feelings of anxiety. There is no evidence to suggest that the client lacks knowledge of the drug therapy.
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A nurse is caring for a client who is receiving alprazolam. The nurse would be alert for which of the following as an initial adverse reaction with this drug?
- A. Heartburn
- B. Anorexia
- C. Headache
- D. Allergy
Correct Answer: C
Rationale: The nurse should assess for headache as the initial adverse reaction in the client after administering alprazolam. Heartburn, anorexia, and allergy are adverse reactions observed in the client after administering salicylates.
A client receiving antianxiety drug therapy complains of constipation. The nurse understands that this is the result of which of the following?
- A. Excess fibrous food in the diet
- B. Overdose of an antianxiety drug
- C. Slowed intestinal transit time
- D. Oral administration of the drug
Correct Answer: C
Rationale: Constipation results from the action of the antianxiety agents, which slow intestinal transit time. An increased fiber intake would help combat the constipation. Constipation does not result from an overdose of the drug or from oral administration.
A client is hospitalized and is prescribed diazepam. Before administering the drug, which of the following information should the nurse obtain? Select all that apply.
- A. Complete medical history
- B. Mental status exam
- C. Anxiety level
- D. Pain assessment
- E. Medication history
Correct Answer: A,B,C
Rationale: Before starting anxiolytic therapy in a hospitalized client, the nurse obtains a complete medical history, including mental status and anxiety level.
During assessment of a client, a nurse suspects that the client is experiencing anxiety. Which of the following would support the nurse's suspicion? Select all that apply.
- A. Facial flushing
- B. Tense posture
- C. Extreme restlessness
- D. Somnolence
- E. Facial grimaces
Correct Answer: B,C,E
Rationale: During the intake history, the nurse observes the client for behavioral signs indicating anxiety (e.g., inability to focus, extreme restlessness, facial grimaces, tense posture).
A nurse is preparing a teaching plan for a client who is prescribed an anxiolytic. As part of the plan, the nurse addresses medications that should be avoided to reduce the risk of increased CNS depression and sedation. Which of the following would the nurse include? Select all that apply.
- A. Alcohol
- B. Analgesics
- C. Digoxin
- D. Tricyclic antidepressants
- E. Antipsychotics
Correct Answer: A,B,D,E
Rationale: Alcohol, analgesics, tricyclic antidepressants, and antipsychotics should be used with caution with anxiolytics due to increased CNS depression and increased risk of sedation.