Nokea
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).
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A nurse is caring for a client who is receiving alprazolam. The nurse would be alert for which of the following as an initial adverse reaction with this drug?
- A. Heartburn
- B. Anorexia
- C. Headache
- D. Allergy
Correct Answer: C
Rationale: The nurse should assess for headache as the initial adverse reaction in the client after administering alprazolam. Heartburn, anorexia, and allergy are adverse reactions observed in the client after administering salicylates.
A client admitted to the health care facility for alcohol withdrawal has been prescribed an antianxiety medication. The nurse instructs the client about the need for cessation of alcohol consumption based on the understanding that the client would be at increased risk for which of the following?
- A. Antianxiety drug toxicity
- B. Respiratory depression
- C. Sedation
- D. CNS depression
Correct Answer: D
Rationale: The nurse should suggest that the client stop consuming alcohol while therapy is going on because such consumption increases the risk for CNS depression. Increased risk for digitalis toxicity is identified when the client is taking digoxin for management of cardiac problems. Increased risk for sedation and respiratory depression is identified when tricyclic antidepressants or antipsychotics are being used simultaneously with an antianxiety agent.
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.
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.