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A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions?
- A. I will need scheduled bloodwork in order to monitor for toxic levels of this drug.
- B. I wont stop taking this medication abruptly, because there could be serious complications.
- C. I will not drink alcohol while taking this medication.
- D. I wont take extra doses of this drug because I can become addicted.
Correct Answer: A
Rationale: The correct answer is A because the statement indicates a misunderstanding. Benzodiazepines do not require routine blood monitoring for toxicity. Benzodiazepines are typically monitored based on clinical response and potential side effects. Choices B, C, and D are all correct statements related to benzodiazepine use, emphasizing the importance of not abruptly stopping the medication, avoiding alcohol, and not taking extra doses to prevent addiction.
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A nurse concludes that a restless, agitated client is manifesting a fight-or-flight response. The nurse should associate this response with which neurotransmitter?
- A. Dopamine
- B. Serotonin
- C. Norepinephrine
Correct Answer: C
Rationale: The correct answer is C, Norepinephrine. During the fight-or-flight response, the sympathetic nervous system is activated, leading to the release of norepinephrine. Norepinephrine increases heart rate, blood pressure, and alertness, preparing the body to either fight or flee from a perceived threat. Dopamine (A) is more related to reward and pleasure. Serotonin (B) is involved in regulating mood and emotions. Cortisol (D) is a stress hormone, not a neurotransmitter involved in the fight-or-flight response.
A client is prescribed alprazolam (Xanax) for acute anxiety. What client history should cause a nurse to question this order?
- A. History of alcohol dependence
- B. History of personality disorder
- C. History of schizophrenia
- D. History of hypertension
Correct Answer: A
Rationale: The correct answer is A: History of alcohol dependence. Alprazolam is a benzodiazepine and can be addictive, especially for individuals with a history of substance abuse like alcohol dependence. This client population is at higher risk for misuse, addiction, and overdose. It is important for the nurse to question this order to avoid potential harm. Choices B, C, and D are incorrect as they do not directly impact the safety or efficacy of alprazolam for acute anxiety.
When an individuals stress response is sustained over a long period of time, which physiological effect of the endocrine system should a nurse anticipate?
- A. Decreased resistance to disease
- B. Increased libido
- C. Decreased blood pressure
- D. Increased inflammatory response
Correct Answer: A
Rationale: The correct answer is A: Decreased resistance to disease. Prolonged stress can weaken the immune system, making individuals more susceptible to illnesses. Chronic stress suppresses immune functions, leading to decreased resistance to diseases. The other choices are incorrect because increased libido (B) and decreased blood pressure (C) are not typical physiological effects of sustained stress. While stress can lead to increased inflammatory response (D), the primary concern with chronic stress is its negative impact on the immune system, making choice A the most appropriate answer in this context.
Which therapeutic communication technique is being used in this nurseclient interaction? Client: When I get angry, I get into a fistfight with my wife or I take it out on the kids. Nurse: I notice that you are smiling as you talk about this physical violence.
- A. Encouraging comparison
- B. Exploring
- C. Formulating a plan of action
- D. Making observations
Correct Answer: D
Rationale: The correct answer is D, Making observations. The nurse is objectively stating what they notice, which is the client smiling while discussing physical violence. This technique helps bring awareness to the client's behavior without judgment. Encouraging comparison (A) involves asking the client to compare similarities and differences, which is not present in this interaction. Exploring (B) involves delving deeper into the client's thoughts and feelings, which is not demonstrated here. Formulating a plan of action (C) involves working with the client to create a plan for addressing issues, which is not the focus of the nurse's statement.
To promote self-reliance, how should a psychiatric nurse best conduct medication administration?
- A. Encourage clients to request their medications at the appropriate times.
- B. Refuse to administer medications unless clients request them at the appropriate times.
- C. Allow the clients to determine appropriate medication times.
- D. Take medications to the clients bedside at the appropriate times.
Correct Answer: A
Rationale: The correct answer is A because it promotes self-reliance by empowering clients to take responsibility for their own medication schedule. By encouraging clients to request their medications at the appropriate times, the nurse fosters autonomy and self-management.
Choice B is incorrect as it is too extreme and may compromise client safety by withholding medications based solely on client request. Choice C is incorrect as it puts the responsibility solely on the client without appropriate guidance from the nurse. Choice D is incorrect as it does not actively involve the client in the medication administration process.