A registered nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled "clonazepam". What is the nurse's first action?

Initiate vomiting and apply an enema.

Check pupil size and reflexes.

Establish a patent airway.

Administer IV fluids fast.

Answer and Explanation

The Correct Answer is C

Choice A rationale: Initiating vomiting and applying an enema is not the first action to take when finding an unconscious person. This could potentially cause more harm, especially if the person is unconscious as they could choke. It’s also important to note that inducing vomiting is not a recommended procedure for drug overdoses as it can lead to aspiration, which can cause more harm.

Choice B rationale: Checking pupil size and reflexes is important in assessing a patient’s neurological status. However, it is not the first action to take. The first action should always be to ensure the patient has a patent airway to allow for adequate oxygenation.

Choice C rationale: Establishing a patent airway is the correct first action when finding an unconscious person. This is because maintaining a patent airway is crucial for oxygenation and ventilation. Without a patent airway, the person could suffer from hypoxia, which could lead to brain damage or death.

Choice D rationale: Administering IV fluids fast is not the first action to take when finding an unconscious person. While IV fluids may be necessary later on in the management of the patient, the first action should always be to ensure the patient has a patent airway.

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Correct Answer is A

Explanation

Choice A rationale: Identifying triggers for anxiety reactions is a crucial part of managing chronic anxiety. By recognizing what situations, thoughts, or feelings provoke anxiety, the client can begin to develop coping strategies to handle these triggers effectively. This approach is often used in cognitive-behavioral therapy, which is a common treatment for anxiety disorders.

Choice B rationale: While contacting a crisis counselor can be helpful in acute situations, it may not be necessary for a client with chronic anxiety to do so on a weekly basis. Regular therapy sessions with a mental health professional would likely be more beneficial, as they can provide ongoing support and help the client develop long-term coping strategies.

Choice C rationale: It’s unrealistic and unfeasible to completely eliminate stress and anxiety from daily life. Stress is a normal part of life, and everyone experiences it to some degree. Instead, the focus should be on managing stress and anxiety effectively through techniques such as relaxation exercises, mindfulness, and cognitive-behavioral strategies.

Choice D rationale: Trying to repress feelings of anxiety can actually exacerbate them. It’s important for individuals with anxiety disorders to acknowledge their feelings and learn how to manage them, rather than trying to suppress them. Repression can lead to increased anxiety and other mental health issues over time.

A. Altered body image. B. Amenorrhea. C. Hyperactivity. D. Bradycardia. E. Verbalized desire to gain weight.

Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale:

Altered body image is a hallmark feature of eating disorders. Individuals with eating disorders often have a distorted perception of their bodies, believing they are overweight or larger than they actually are. This distorted body image can lead to intense dissatisfaction with their appearance, even when they are underweight. They may engage in obsessive behaviors such as repeatedly checking their weight, measuring their body parts, and avoiding mirrors. They may also fixate on perceived flaws in their appearance, leading to significant distress and impairment in their daily lives.

Choice B rationale:

Amenorrhea, the absence of menstruation, is a common physiological consequence of eating disorders. It occurs due to hormonal imbalances caused by insufficient intake of calories and nutrients, particularly fat. The body requires a certain amount of body fat to maintain normal reproductive function. When body fat levels fall below a critical threshold, the hypothalamus, a part of the brain that regulates hormone production, signals the pituitary gland to reduce the production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). These hormones play crucial roles in ovulation and menstruation. Without adequate levels of FSH and LH, ovulation and menstruation do not occur.

Choice C rationale:

Hyperactivity, characterized by excessive energy and restlessness, can manifest in individuals with eating disorders. This increased activity level may be a way to burn calories or compensate for perceived overeating. It may also be a way to distract themselves from thoughts about food and body image. The hyperactivity can present in various forms, such as excessive exercise, fidgeting, or constant movement.

Choice D rationale:

Bradycardia, a slower-than-normal heart rate, is another physiological sign that can accompany eating disorders. It occurs as the body attempts to conserve energy in response to inadequate caloric intake. The heart rate slows down to minimize energy expenditure. Bradycardia can have serious health implications, including fatigue, dizziness, fainting spells, and potentially life- threatening heart arrhythmias.

Choice E rationale:

Verbalized desire to gain weight is not a typical manifestation of eating disorders. Individuals with eating disorders often have a strong fear of weight gain and a persistent drive for thinness. They may actively resist efforts to increase their weight, even when they are dangerously underweight.

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A registered nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled "clonazepam". What is the nurse's first action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A mental health nurse is preparing a client who has chronic anxiety for discharge from the psychiatric unit. Which of the following instructions should the nurse include in the client's discharge plan?

Correct Answer is A

Explanation

A nurse is caring for an adolescent female who has an eating disorder.The client is 162.6 cm (64 in) tall and weighs 38.56 kg (85 lb). Upon assessment, which of the following manifestations should the nurse expect? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

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