Nokea
A nurse is preparing to administer an anxiolytic agent via intramuscular injection. Which of the following would be most important for the nurse to keep in mind? Select all that apply.
- A. The client should be monitored closely for 3 hours postinjection.
- B. Intramuscular injection should be given in chronic states.
- C. The client should remain in a lying position for about 30 minutes.
- D. The drug should be administered into a large muscle mass.
- E. The client should be kept conscious for at least 1 hour after administration.
Correct Answer: A,D
Rationale: Intramuscular administration of an anxiolytic should be done primarily in an acute state. The drug should be administered in a large muscle mass, the client should be observed closely for at least 3 hours, and the client should be kept lying down for 30 minutes to 3 hours after drug administration.
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A client who is receiving a benzodiazepine tells the nurse that his mouth feels really dry. Which of the following would the nurse include in the teaching plan for this client?
- A. Try drinking about 8 ounces of water at least every 2 hours.
- B. Sucking on hard sugarless candy might help you.
- C. Make sure you eat a lot of green leafy vegetables.
- D. Change your position slowly as you get out of bed.
Correct Answer: B
Rationale: For dry mouth, the nurse should suggest sucking on hard, sugarless candies or chewing sugarless gum. Frequent sips of water would also help, but drinking 8 ounces of water every 2 hours could lead to fluid overload. Eating green leafy vegetables would help with constipation. Changing positions slowly would be appropriate if the client reported dizziness or lightheadedness.
A client who was receiving a benzodiazepine for treatment of anxiety tells the nurse that he has decided to discontinue the treatment. Which of the following would the nurse include in the teaching plan for this client?
- A. Be sure to gradually decrease the dosage over time.
- B. It's fine to just stop taking the medication.
- C. You need to first increase the dose and then stop.
- D. It's important that you continue the medication even if you want to stop.
Correct Answer: A
Rationale: The nurse should suggest the client gradually decrease the dosage schedule to avoid withdrawal symptoms. It is not advisable for the nurse to suggest just stopping the medication, increasing the dosage, or continuing with the medication as prescribed.
After administering an anxiolytic, the nurse assesses the client for adverse reactions. Which of the following would the nurse identify as a common early reaction to this group of drugs? Select all that apply.
- A. Headache
- B. Sedation
- C. Lightheadedness
- D. Dizziness
- E. Hypertension
Correct Answer: A,B,C,D
Rationale: Common early reactions caused by anxiolytics include mild drowsiness, sedation, lightheadedness, dizziness, and headache.
Before administering a prescribed anxiolytic to a client, which of the following would the nurse include in the physical assessment of the client? Select all that apply.
- A. Blood pressure
- B. Blood glucose
- C. Pulse
- D. Respiratory rate
- E. Weight
Correct Answer: A,C,D,E
Rationale: The nurse's preadministration physical assessment for the administration of an anxiolytic should include blood pressure, pulse, respiratory rate, and weight.
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).