A nurse is caring for a client who is seeking treatment for opioid use disorder. Which of the following actions should the nurse take?

Request a prescription for varenicline from the client's provider.

Initiate facility procedures for emergency commitment.

Inform the client about policies for dispensing methadone.

Assess the client using the CAGE questionnaire.

Answer and Explanation

The Correct Answer is C

A. Request a prescription for varenicline from the client's provider.
Varenicline is used to help people quit smoking and is not indicated for the treatment of opioid use disorder.

B. Initiate facility procedures for emergency commitment.
Emergency commitment typically involves legal procedures and should only be pursued if the client poses an immediate danger to themselves or others. It is not the appropriate action in this scenario without further information indicating such a need.

C. Inform the client about policies for dispensing methadone.
Methadone is a medication used to help people reduce or quit their use of heroin or other opiates. Methadone is dispensed under strict regulations and guidelines due to its potential for misuse. The nurse should inform the client about the policies and procedures related to the dispensing of methadone, ensuring the client understands the rules and requirements associated with its use.

D. Assess the client using the CAGE questionnaire.
The CAGE questionnaire is a tool used to screen for alcohol use disorder, not opioid use disorder. While it's essential to assess the client comprehensively, using appropriate tools, in this case, informing the client about methadone dispensing policies is the most relevant action.

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Correct Answer is C

Explanation

A. Summarize the objectives the client achieved during the relationship:
This intervention is more appropriate for the termination phase of the nurse-client relationship. During termination, the nurse summarizes the progress made, goals achieved, and skills learned during the therapeutic relationship. This helps both the nurse and the client reflect on the journey and celebrate accomplishments.

B. Present issues regarding confidentiality:
Discussing confidentiality is crucial and typically occurs in the orientation phase of the nurse-client relationship. Establishing trust and clarifying the boundaries of confidentiality early in the relationship helps the client feel secure and promotes open communication. This choice is relevant during the initial stages of the therapeutic relationship.

C. Promote the client's problem-solving skills:
This is the correct choice for the working phase of the nurse-client relationship. In this phase, the focus is on active problem-solving, exploring feelings and thoughts, and encouraging the client to develop coping strategies. The nurse supports the client in identifying problems, generating solutions, and implementing effective strategies. Promoting the client's problem-solving skills is a central aspect of therapeutic work during this phase.

D. Identify the responsibilities of the client and nurse:
Clarifying the responsibilities of both the client and nurse is essential to establish clear roles and expectations. This usually occurs in the orientation phase. During this phase, the nurse explains the purpose of the therapeutic relationship, the roles of both parties and the boundaries of the nurse-client interaction. Establishing clear responsibilities helps create a foundation for a respectful and effective therapeutic alliance.

A. "This medication is given to help with extrapyramidal side effects." B. "Benztropine helps alleviate your hallucinations." C. "This medication is given to help with your depression." D. "Benztropine is used to counteract your tachycardia."

Correct Answer is A

Explanation

A. "This medication is given to help with extrapyramidal side effects."
Benztropine is an anticholinergic medication used to treat the extrapyramidal side effects (EPS) caused by certain psychiatric drugs, particularly antipsychotics. EPS can include symptoms such as muscle stiffness, restlessness, tremors, and other movement disorders. Benztropine helps to alleviate these symptoms, making it an essential medication for individuals experiencing these side effects from antipsychotic medications.

B. "Benztropine helps alleviate your hallucinations."
This statement is incorrect. Benztropine is not primarily used to treat hallucinations; it is used for movement-related side effects as mentioned above.

C. "This medication is given to help with your depression."
This statement is incorrect. Benztropine is not indicated for the treatment of depression.

D. "Benztropine is used to counteract your tachycardia."
This statement is incorrect. Benztropine is not used to treat tachycardia (fast heart rate). It is specifically used for extrapyramidal side effects related to antipsychotic medications.

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