Nokea
Which information is most appropriate for the nurse to tell the client about taking alprazolam (Xanax)?
- A. Avoid consuming alcohol while taking this drug.
- B. Take the medication with a full meal.
- C. This drug can cause insomnia in some people.
- D. A blood test will be required periodically.
Correct Answer: A
Rationale: Alcohol potentiates alprazolam's sedative effects, increasing the risk of respiratory depression and overdose, making this a critical instruction.
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The client has been placed in involuntary seclusion. Which assessment observation best indicates to the nurse the client’s readiness to leave involuntary seclusion?
- A. The client calmly stating “I have control over my anger now.”
- B. BP is 110/64 mm Hg; P is 82 bpm and regular; R is 16 bpm and regular.
- C. Client is observed sitting in seclusion room doorway asking staff for a drink.
- D. Medical record states “Seclusion of 45 minutes resulted in improved control.”
Correct Answer: C
Rationale: Sitting in the doorway and requesting a drink (C) shows tolerance to stimuli. Statements (A) vital signs (B) and records (D) are less definitive than observed behavior.
Which recommendation by the nurse is most likely to be effective in helping the client control bulimia?
- A. Eat small, frequent meals.
- B. Take a daily inventory of food offered at the dormitory.
- C. Avoid eating in fast food establishments.
- D. Keep a daily calorie count of all foods consumed.
Correct Answer: A
Rationale: Small, frequent meals stabilize eating patterns, reducing the urge to binge and purge, a key strategy in managing bulimia.
The client undergoing a routine physical exam asks the nurse if taking the dietary supplement androstenedione sometimes referred to as “andro” would help to get in shape for football season. Which statement by the nurse is best?
- A. “Androstenedione is considered a dietary supplement and therefore is not guaranteed safe by FDA standards.”
- B. “Benefits of androstenedione have not been proven. In fact there appear to be more negative effects than benefits.”
- C. “Taking androstenedione supplements is similar to taking vitamin supplements. Andro is found in meats so the tablet forms are safe.”
- D. “Androstenedione supplements have been proven to be perfectly safe because it is a naturally occurring hormone that is the precursor for testosterone.”
Correct Answer: B
Rationale: Androstenedione lacks proven benefits and has negative effects (B). FDA oversight (A) is partial meat comparison (C) is false and safety (D) is unproven.
If the client frequently comes to meals with the residue of soap on the face or an unbuttoned shirt, which action by the nurse is most beneficial to the client's emotional state?
- A. Send the client back to finish.
- B. Bathe and dress the client daily.
- C. Schedule the client's hygiene activities after meals.
- D. Comment on how self-reliant the client is.
Correct Answer: C
Rationale: Scheduling hygiene after meals allows assistance without embarrassment, supporting the client's dignity and emotional well-being.
The client states “I go out just about every weekend and drink pretty heavily with my friends. Does that mean I’m dependent on alcohol?” Which is the best response by the nurse?
- A. “You’re not dependent on alcohol if you never drink to the point of intoxication.”
- B. “It sounds like you feel guilty about how much you drink. Tell me more about this.”
- C. “With dependence you have a strong need to drink and feel uncomfortable if you don’t.”
- D. “You could be dependent. Consuming alcohol pretty heavily every weekend is excessive.”
Correct Answer: C
Rationale: Dependence involves a compulsive need causing distress if unmet (C). Intoxication (A) or frequency (D) don’t define it and guilt (B) is irrelevant.