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A nurse is teaching a female client who has an anxiety disorder and is prescribed alprazolam (Xanax). Which of the following information should the nurse include in the teaching?
- A. If a dose is missed, do not double the next dose of medication.
- B. This medication may cause dizziness upon standing.
- C. Use a dependable form of contraception while taking this medication.
- D. Do not drink alcohol while taking this medication.
Correct Answer: B
Rationale: The correct answer is B: This medication may cause dizziness upon standing. Alprazolam is a benzodiazepine that can cause dizziness as a side effect, especially when standing up quickly. This information is important for the client to prevent falls or accidents.
A: Missing a dose should not be addressed by doubling the next dose as it can lead to overdose or adverse effects.
C: Although contraceptives might be important to discuss, it is not specifically related to the medication itself.
D: Alcohol should be avoided while taking alprazolam due to the increased risk of side effects and potential interactions, but it is not the most crucial information for the client's safety.
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A nurse is caring for a client who is refusing to attend group therapy. The client states,I don't know why you think I need therapy. I am fine without it. Which of the following responses by the nurse indicates a therapeutic response?
- A. I understand that you feel like you don't need it; however, the provider thinks it will help.
- B. You don't feel like group therapy is for you. Tell me more about what you know about group therapy.
- C. I am not saying that you need therapy, but I am sure it will help you.
- D. You don't have to be afraid to go. Our therapists are very understanding.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Option B demonstrates therapeutic communication by showing empathy and understanding towards the client's feelings and inviting further discussion. By encouraging the client to express their thoughts on group therapy, the nurse opens up a dialogue to explore the client's beliefs and concerns, fostering trust and rapport. This approach respects the client's autonomy and promotes client-centered care.
Summary of Incorrect Choices:
A: This response dismisses the client's feelings and focuses on the provider's opinion, potentially alienating the client and not addressing their concerns.
C: This response minimizes the client's feelings and imposes the nurse's beliefs, which may lead to resistance and hinder the therapeutic relationship.
D: This response invalidates the client's emotions by assuming fear as the underlying issue and may create defensiveness rather than addressing the client's actual concerns.
A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of the flu. During the night shift,the client is found climbing into the bed of another client who becomes upset and scared. Which of the following actions should the nurse take?
- A. Medicate the patient with antipsychotics.
- B. Assist the client to the correct room.
- C. Move the client to a room at the end of the hall.
- D. Place the client in restraints.
Correct Answer: B
Rationale: The correct answer is B: Assist the client to the correct room. This is the appropriate action as it addresses the immediate issue of the client being in the wrong room, which is causing distress to the other client. Moving the client to the correct room ensures safety and comfort for both clients. Medicating with antipsychotics (choice A) is not the first-line intervention in this situation and should be avoided unless absolutely necessary due to potential side effects. Moving the client to a room at the end of the hall (choice C) may not address the underlying issue and can isolate the client unnecessarily. Placing the client in restraints (choice D) should be avoided as it can be traumatic and is not indicated in this scenario.
A nurse is caring for a client who reports increased anxiety and nervousness,heat intolerance,and unintentional weight loss. Blood testing reveals decreased thyroid-stimulating hormone (TSH),elevated thyroxine (T4) and elevated triiodothyronine (T3) levels. Which of the following vital sign abnormalities does the nurse anticipate?
- A. Hypotension
- B. Tachycardia
- C. Slow respiratory rate
- D. Decreased body temperature
Correct Answer: B
Rationale: The correct answer is B: Tachycardia. In this scenario, the client is showing symptoms of hyperthyroidism, such as increased anxiety, nervousness, heat intolerance, and unintentional weight loss. The decreased TSH and elevated T4/T3 levels indicate an overactive thyroid gland.
Tachycardia is a common symptom of hyperthyroidism due to the increased metabolic rate caused by excess thyroid hormones. The body's response to the increased metabolism is to speed up the heart rate to meet the increased demand for oxygen and nutrients. Therefore, the nurse can anticipate tachycardia in this client.
The other options are incorrect because hypotension is not typically associated with hyperthyroidism; slow respiratory rate is not a common vital sign abnormality seen in hyperthyroidism; decreased body temperature is unlikely as hyperthyroidism usually causes heat intolerance and increased body temperature.
Charles, the nurse, is working in an emergency department and is assessing a preschool-age child who reports abdominal pain. Which of the following findings should alert the nurse to possible abuse (select all that apply)
- A. Areas of ecchymosis on the torso.
- B. Mismatched clothing
- C. Abrasions on knees
- D. Abdominal rebound tenderness
- E. Round burn marks on forearms
Correct Answer: A,E
Rationale: The correct answers are A and E. Ecchymosis on the torso may indicate physical abuse, and burn marks on the forearms suggest possible abuse as well. Mismatched clothing (B) is not a direct indicator of abuse but may suggest neglect. Abrasions on knees (C) are common in preschool-age children and do not specifically point to abuse. Abdominal rebound tenderness (D) is a medical finding that may indicate a health issue but does not directly correlate with abuse. Overall, A and E are the most concerning findings that should alert the nurse to possible abuse.
A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium?
- A. A client attempts to climb out of bed and repeatedly states she must get home.
- B. A client refuses to get out of bed and has no motivation to attend to daily hygiene.
- C. A client wants to know the current time while there is a clock on the wall.
- D. A client requests extra blankets when the thermostat in the room indicates 25.6°C (78°F).
Correct Answer: A
Rationale: The correct answer is A. Delirium is characterized by sudden onset confusion and disorientation. In this case, the client attempting to climb out of bed and repeatedly stating she must get home indicates altered mental status and confusion, which are common in delirium. The other choices do not align with typical manifestations of delirium. Choice B suggests lack of motivation, choice C is a normal behavior to check the time, and choice D is a reasonable request based on personal preference rather than a sign of delirium.