A client experiencing withdrawal from the benzodiazepine alprazolam is demonstrating severe agitation and tremors. Which is the best initial nursing action?
Instruct the family about withdrawal symptoms.
Initiate seizure precautions.
Obtain a serum drug screen.
Administer naloxone per PRN protocol.
The Correct Answer is B
A. Instruct the family about withdrawal symptoms. While educating the family about withdrawal symptoms is important for support and understanding, it is not the best initial action when the
client is experiencing severe agitation and tremors. Safety measures should be prioritized.
B. Initiate seizure precautions. Severe agitation and tremors can be signs of benzodiazepine withdrawal, which may progress to seizures. Initiating seizure precautions, such as ensuring a
safe environment, padding side rails, and having emergency medications and equipment readily available, is the priority to prevent injury.
C. Obtain a serum drug screen. While obtaining a serum drug screen may be necessary to confirm benzodiazepine withdrawal, it is not the immediate action needed to address the client's current symptoms and prevent potential harm.
D. Administer naloxone per PRN protocol. Naloxone is an opioid antagonist used to reverse opioid overdose and is not indicated for benzodiazepine withdrawal. Administering naloxone would not be appropriate or effective in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Immunological Administer antihistamine
The correct answer is to administer antihistamine. Antihistamines can help alleviate symptoms of an allergic reaction, such as itching, hives, and swelling, by blocking the effects of histamine
released during the allergic response.
Cardiovascular
Monitor vital signs continuously
The correct answer is to monitor vital signs continuously. Continuous monitoring of vital signs, including blood pressure, heart rate, and oxygen saturation, is essential to detect any changes in the client's cardiovascular status, especially after experiencing adverse reactions to medication.
Provide warmth
Providing warmth can help improve peripheral circulation and comfort for the client, especially if they are experiencing symptoms such as dizziness or feeling cold due to a drop in blood pressure.
Respiratory
Assess lung sounds
The correct answer is to assess lung sounds. Assessing lung sounds can help determine if the client is experiencing any respiratory distress or complications, such as wheezing or crackles, which may indicate a need for further intervention or respiratory support.
Chest x-ray
Ordering a chest x-ray can help evaluate the client's respiratory status, especially if there are concerns about potential complications such as pneumonia or pulmonary edema. It allows for the assessment of lung fields and can provide valuable information about the client's respiratory function.
Correct Answer is B
Explanation
A. Collaborating with a science teacher to prepare a health lesson may be beneficial for health education but does not directly address secondary prevention. Secondary prevention involves early detection and intervention to prevent the progression of disease or injury.
B. Initiating a hearing and vision screening program for first graders is an example of secondary prevention. This action aims to detect any hearing or vision problems early, allowing for timely intervention and management to prevent further complications or difficulties in learning and
development.
C. Preparing a presentation on how to prevent the spread of lice may be important for promoting hygiene and preventing infestations, but it falls more under the category of health education and primary prevention rather than secondary prevention.
D. Observing a person with type 1 diabetes mellitus self-administer a dose of insulin may be related to health education or management of a chronic condition, but it does not directly address secondary prevention for school-aged children.
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