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An elderly client was prescribed Ativan 1 mg three times a day to help calm her anxiety after her husband's death. The next day the client calls her daughter asking when she is picking her up to go to the graveside. The client says she has been walking up and down the driveway for the past hour waiting for her daughter. Noting the client's agitation, hyperactivity, and insistence, the daughter calls the nurse to report her mother's behavior. What should the nurse suspect?
- A. The client is manic and may need a sleeping pill
- B. The client is experiencing a medication interaction and should go to the ED
- C. The client is experiencing a paradoxical reaction to the Ativan and should stop the new medication immediately
- D. The client is overcome by grief and probably needs an antidepressant
Correct Answer: C
Rationale: A paradoxical reaction to Ativan, where the drug causes opposite effects such as increased agitation and hyperactivity, should prompt immediate cessation of the medication. In this scenario, the client was prescribed Ativan to help calm her anxiety, but instead, she is displaying symptoms of increased agitation and hyperactivity, indicating a paradoxical reaction. Choice A is incorrect because the symptoms described do not align with mania. Choice B is incorrect as there is no mention of a medication interaction. Choice D is incorrect as the symptoms are more indicative of a paradoxical reaction rather than overwhelming grief.
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A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage?
- A. He ingested the drug 3 hours prior to admission to the emergency center.
- B. The family reports that he took an entire bottle of acetaminophen (Tylenol).
- C. He is unresponsive to instructions and is unable to cooperate with emetic therapy.
- D. Those with repeated suicide attempts desire punishment to relieve their guilt.
Correct Answer: C
Rationale: The correct answer is C because the client's unresponsiveness and inability to cooperate with emetic therapy indicate the need for gastric lavage. Gastric lavage is a procedure used to remove toxic substances from the stomach in cases where the patient is unresponsive or unable to cooperate. Choice A is incorrect as the time of ingestion alone does not indicate the need for gastric lavage. Choice B, although indicating a significant overdose, does not directly necessitate gastric lavage. Choice D is incorrect as it provides information about the possible psychological motivation for repeated suicide attempts, but it is not directly related to the immediate need for gastric lavage in this scenario.
What is the most appropriate nursing intervention for a client with obsessive-compulsive disorder (OCD) who is constantly washing her hands?
- A. Allow the client to continue washing her hands.
- B. Set limits on the time spent washing her hands.
- C. Encourage the client to wash her hands less frequently.
- D. Assist the client in finding alternative ways to reduce anxiety.
Correct Answer: D
Rationale: Assisting the client in finding alternative ways to reduce anxiety is the most appropriate intervention for a client with OCD who is constantly washing her hands. This approach helps address the underlying cause of the compulsive behavior by focusing on reducing anxiety rather than reinforcing the behavior. Allowing the client to continue washing her hands (choice A) would not address the root of the issue and may perpetuate the behavior. Setting limits on the time spent washing hands (choice B) may cause distress to the client and does not address the core problem. Encouraging the client to wash her hands less frequently (choice C) does not provide effective coping strategies for managing anxiety associated with OCD.
A client is admitted to the hospital with a diagnosis of anorexia nervosa. What is the most important intervention for the LPN/LVN to implement during the first 24 hours of hospitalization?
- A. Encourage the client to eat small, frequent meals.
- B. Monitor the client's vital signs and weight.
- C. Establish a trusting relationship with the client.
- D. Provide emotional support to the client.
Correct Answer: B
Rationale: The correct answer is to monitor the client's vital signs and weight. This intervention is crucial in assessing the severity of the client's condition and planning appropriate care. Vital signs and weight monitoring help in evaluating the client's physiological status and identifying any immediate concerns related to anorexia nervosa. Choices A, C, and D are important aspects of care for a client with anorexia nervosa; however, during the initial 24 hours of hospitalization, monitoring vital signs and weight takes precedence as it provides essential data for the client's ongoing management and treatment.
The LPN/LVN is caring for a client who is experiencing alcohol withdrawal. Which intervention should the nurse implement first?
- A. Administer a PRN dose of lorazepam (Ativan).
- B. Monitor the client's vital signs.
- C. Place the client on seizure precautions.
- D. Encourage the client to express feelings about withdrawal.
Correct Answer: B
Rationale: When caring for a client experiencing alcohol withdrawal, the first intervention the nurse should implement is to monitor the client's vital signs. Vital sign monitoring is crucial to assess for any potential complications such as hypertension, tachycardia, fever, or other signs of autonomic hyperactivity. Administering medication like lorazepam (Ativan) would come after assessing the vital signs to determine the need for pharmacological intervention. Placing the client on seizure precautions is important, but assessing vital signs takes precedence to ensure immediate safety. Encouraging the client to express feelings about withdrawal is a supportive intervention but does not address the immediate physiological risk associated with alcohol withdrawal.
The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding(s)?
- A. Dizziness when standing.
- B. Shuffling gait and hand tremors.
- C. Urinary retention.
- D. Fever of 102°F.
Correct Answer: D
Rationale: A fever (D) may indicate neuroleptic malignant syndrome (NMS), a potentially fatal complication of antipsychotics. The healthcare provider should be contacted before administering the next dose of Haldol. Dizziness when standing (A), shuffling gait and hand tremors (B), and urinary retention (C) are all adverse effects of Haldol that, while concerning, do not pose immediate life-threatening risks compared to the potential severity of NMS indicated by a fever.