A nurse is caring for a client in the emergency department (ED).

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Alcohol withdrawal syndrome refers to the collection of symptoms that occur when individuals who are dependent on alcohol abruptly reduce or stop their alcohol intake.

Benzodiazepines, such as diazepam or lorazepam, are commonly used to manage symptoms such as anxiety, tremors, and seizures.

Providing a safe environment also ensures that the client does not involve in self-harming activities due to hallucinations.

Alcohol withdrawal syndrome is associated with an increased risk of seizures, particularly within the first 48 hours after cessation of alcohol consumption. Seizures can range from mild to severe and may be life-threatening if not promptly managed.

Chronic alcohol abuse can lead to dehydration and electrolyte imbalances due to increased urinary output, decreased fluid intake, and poor nutrition. Additionally, alcohol withdrawal itself can exacerbate fluid and electrolyte disturbances due to vomiting, diarrhea, diaphoresis, and increased metabolic demand.

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Correct Answer is A

Explanation

A. Fluoxetine and other selective serotonin reuptake inhibitors (SSRIs) typically require several weeks of treatment before the full therapeutic effects are realized. Therefore, it's important for the nurse to reassure the client that it may take some time for the medication to alleviate depressive symptoms fully.

B. While lack of improvement in depressive symptoms after two weeks of fluoxetine treatment may be concerning, it's generally recommended to wait at least 4 to 6 weeks before considering changing or adjusting the antidepressant regimen.

C. Monoamine oxidase inhibitors (MAOIs) are another class of antidepressant medications that may be considered for treatment-resistant depression. However, MAOIs have significant dietary and medication restrictions and carry the risk of potentially serious drug interactions.

D. While sleep disturbances are common in major depressive disorder, recommending a sleep study as the first intervention for a client who is not responding to antidepressant treatment after only two weeks may not be the most appropriate action.

A. Provide a stimulating environment. B. Schedule daily seclusion times. C. Have consistent unit routines. D. Discourage daytime napping.

Correct Answer is C

Explanation

C. Consistent unit routines are essential for clients in the manic phase of bipolar disorder. Maintaining a structured environment with predictable routines can help stabilize mood, reduce agitation, and provide a sense of security for the client.

A. Mania is characterized by heightened activity, impulsivity, and sometimes agitation. Providing a stimulating environment may exacerbate these symptoms and increase the risk of escalating behaviors or agitation.

B. While it may be necessary to provide a safe and quiet space for the client if they become agitated or overwhelmed, scheduling daily seclusion times implies isolation, which can worsen feelings of loneliness or distress.

D. Excessive daytime napping can disrupt the client's sleep-wake cycle and exacerbate symptoms of mania.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has major depressive disorder and was prescribed fluoxetine 2 weeks ago. The client reports having an improved appetite, but still feels very depressed and is still having trouble sleeping. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care?

Correct Answer is C

Explanation

A nurse is caring for a client with paranoid personality disorder who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?

The nurse is doing an admission assessment on a client with schizophrenia. Which of the following are positive symptoms of schizophrenia?

A nurse in a hospital is caring for a client who has agoraphobia. Which of the following statements by the client indicates understanding of the goals of treatment?

A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (Select all that apply)

A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?

A client is admitted for a drug overdose with a barbiturate. Which is the priority nursing action when planning care for this client?

A client is seeking treatment for a specific phobia. The nurse in the anxiety disorders clinic documents that the client's anxiety is related to exposure to the phobic object. Which is a realistic outcome for anxiety self-control in this situation?