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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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A client diagnosed with cirrhosis is experiencing pruritus. Which strategies are appropriate for the nurse to teach the client to promote comfort and skin integrity? Select all that apply.
- A. Maintain short fingernails to minimize excoriating the skin
- B. Take a bath or shower in hot water to alleviate itching sensations
- C. Take prescribed cholestyramine 1 hour after other medications
- D. Use a moisturizing cream on unbroken skin daily
- E. Wear wool gloves and tight stockings to avoid scratching
Correct Answer: A, C, D
Rationale: Short fingernails (A), cholestyramine timing (C), and moisturizing cream (D) reduce itching and protect skin. Hot water (B) worsens itching, and wool gloves/tight stockings (E) may irritate skin.
A child on the playground is experiencing an anaphylactic reaction. The school nurse arrives with an EpiPen. The weather is cold and the child is wearing several layers of clothing. How should the nurse proceed with the EpiPen?
- A. Inject into the upper arm where the sleeve can be pulled up
- B. Inject into the most accessible vein
- C. Inject through the clothing into thigh and hold in place for 10 seconds
- D. Take the child inside, remove excess clothing, and inject into the thigh
Correct Answer: C
Rationale: Injecting through clothing into the thigh (C) ensures rapid administration during anaphylaxis. Arm injection (A) is incorrect, IV injection (B) is not for EpiPens, and delaying to remove clothing (D) is dangerous.
A client is to be discharged following the removal of a cataract on the right eye. The nurse should tell the client to:
- A. Wear the metal eye shield only during waking hours.
- B. Report any eye pain to the doctor immediately.
- C. Refrain from using a pillow under his head.
- D. Avoid wearing dark glasses inside.
Correct Answer: B
Rationale: Reporting eye pain immediately is critical as it may indicate complications like infection or increased intraocular pressure. The eye shield is typically worn at night or as directed. Using a pillow is not contraindicated. Dark glasses are often recommended to reduce glare.
The nurse is reinforcing teaching about hypoglycemia with a group of clients who have type 1 diabetes mellitus. Which of the following should the nurse include as signs or symptoms of hypoglycemia? Select all that apply.
- A. Diaphoresis
- B. Flushing
- C. Pallor
- D. Polyuria
- E. Trembling
Correct Answer: A, C, E
Rationale: Diaphoresis (A), pallor (C), and trembling (E) are signs of hypoglycemia due to sympathetic activation. Flushing (B) and polyuria (D) are not typical.
An adult who has newly diagnosed angina has been prescribed sublingual nitroglycerin. What should be included in the nurse's teaching about the medication? Select all that apply.
- A. Put the tablets under your tongue and let them dissolve.
- B. Keep the tablets in a dark glass container.
- C. You can take one tablet, and if you still have pain, you can take another tablet in 10 minutes.
- D. Be sure to take nitroglycerin while you are standing up.
- E. You may get a headache shortly after you take the medication,
- F. If your tongue tingles spit out the tablet.
Correct Answer: A,B,E
Rationale: Sublingual nitroglycerin is dissolved under the tongue, stored in dark glass to maintain potency, and may cause headaches as a side effect.