Nokea
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.
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A nurse suspects that a client is experiencing anxiety. Which physical assessment findings would support the nurse's suspicion? Select all that apply.
- A. Hypotension
- B. Decreased respiratory rate
- C. Increased muscle tension
- D. Pale skin
- E. Bradycardia
Correct Answer: C,D
Rationale: Physiological manifestations of anxiety can include hypertension, tachycardia, increased rate and depth of respirations, increased muscle tension, and cool, pale skin.
A nurse is reviewing the medical record of a client with anxiety who is to receive an antianxiety agent as part of the treatment. The nurse recognizes that benzodiazepines would not be used based on which of the following conditions. Select all that apply.
- A. Cataracts
- B. Acute narrow-angle glaucoma
- C. Hypotension
- D. Psychoses
- E. Pregnancy
Correct Answer: B,D,E
Rationale: The use of benzodiazepines is contraindicated in clients with known hypersensitivity, psychoses, acute narrow-angle glaucoma, and pregnancy.
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.
A nurse suspects that a client who is receiving lorazepam may be experiencing benzodiazepine withdrawal based on assessment of which of the following? Select all that apply.
- A. Anxiety
- B. Tremor
- C. Photophobia
- D. Insomnia
- E. Metallic taste
Correct Answer: A,B,C,E
Rationale: Symptoms of benzodiazepine withdrawal include increased anxiety, concentration difficulties, tremor, and sensory disturbances, such as paresthesias, photophobia, hypersomnia, and metallic taste.
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).