A client is experiencing severe agitation and tremors due to withdrawal from the benzodiazepine alprazolam. What is the best initial nursing action?

Obtain a serum drug screen.

Administer naloxone per PRN protocol.

Initiate seizure precautions.

Instruct the family about withdrawal symptoms.

Answer and Explanation

The Correct Answer is C

Choice A rationale
While obtaining a serum drug screen might be helpful in confirming the presence of benzodiazepines or other substances, it is not the most immediate concern in a client experiencing severe agitation and tremors due to withdrawal.
Choice B rationale
Naloxone is an opioid antagonist and would not be effective in managing withdrawal symptoms from benzodiazepines.
Choice C rationale
Seizure precautions should be initiated as withdrawal from benzodiazepines can lead to severe withdrawal symptoms, including seizures. Therefore, ensuring the safety of the client by initiating seizure precautions is the best initial nursing action.
Choice D rationale

While education is an important part of nursing care, in this situation, the client’s immediate physical needs take precedence.

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Correct Answer is D

Explanation

Choice A rationale

While it is essential to assess how the client copes with auditory hallucinations, asking this question alone does not provide specific information about the content of the hallucinations.

Choice B rationale

The timing of the voices can provide some insight into the triggers or patterns of the hallucinations, but it does not directly address the content or potential impact of the hallucinations on the client’s behavior or mental state.

Choice C rationale

While medication efficacy is an important aspect of managing schizophrenia, it does not directly address the current experience of the client’s hallucinations.

Choice D rationale

Understanding what the voices are saying to the client can provide critical information about potential risks, including self-harm or harm to others, and can guide the treatment plan. This is why it is the most important question for the nurse to include in the client’s assessment.

A. Avoid administering oxygen at high levels for extended periods. B. Increase the oxygen rate during sleep to compensate for a slower respiratory rate. C. Taking a sedative at bedtime slows the respiratory rate, which decreases oxygen needs. D. Oxygen is less toxic when it is humidified with a hydration source.

Correct Answer is A

Explanation

Choice A rationale
Oxygen therapy is a crucial part of the management for patients with severe pneumonia. However, prolonged administration of high concentrations of oxygen can potentially lead to oxygen toxicity, resulting in damage to the cells of the lungs. This is due to the production of

reactive oxygen species which can damage cell structures. Therefore, it is important to avoid administering oxygen at high levels for extended periods.
Choice B rationale
While it might seem logical to increase the oxygen rate during sleep due to a slower respiratory rate, this is not typically recommended. The body’s oxygen requirements do not significantly change during sleep and increasing the oxygen rate could potentially lead to hyperoxia.
Choice C rationale
Sedatives can indeed slow the respiratory rate, but this does not decrease oxygen needs. In fact, it could potentially lead to respiratory depression and hypoxia, especially in a patient with a respiratory illness like pneumonia.
Choice D rationale
Humidification of oxygen can improve patient comfort, especially with high flow rates, by preventing dryness in the nasal passages. However, it does not make oxygen less toxic.

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A client is experiencing severe agitation and tremors due to withdrawal from the benzodiazepine alprazolam. What is the best initial nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with schizophrenia is admitted to the hospital reporting auditory hallucinations. Which query is most important for the nurse to include in the client’s assessment?

Correct Answer is D

Explanation

A 10-year-old child with pneumonia is receiving oxygen at 5 L/minute via a nasal cannula. When planning care for this child, what principle of oxygen administration should the nurse keep in mind?

Correct Answer is A

Explanation

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