The nurse is caring for a client who has a history of alcohol use disorder and is experiencing withdrawal symptoms. Which of the following should be the priority action by the nurse?
Support the client's attempt to rebuild damaged interpersonal relationships.
Teach the client about the effects of alcohol dependence and the need for rehabilitation.
Teach the client alternative strategies for managing anxiety.
Prepare to administer Ativan as ordered.
The Correct Answer is D
Choice A reason:
Supporting the client's attempt to rebuild damaged interpersonal relationships is an important long-term goal in the recovery process. However, it is not the immediate priority when a client is experiencing acute withdrawal symptoms, which can be life-threatening.
Choice B reason:
Educating the client about the effects of alcohol dependence and the need for rehabilitation is crucial for long-term recovery and preventing relapse. Nevertheless, during acute withdrawal, the priority is to manage the physical and psychological symptoms safely.
Choice C reason:
Teaching the client alternative strategies for managing anxiety is a valuable part of therapy and helps in long-term coping. However, during acute withdrawal, the client may not be able to learn or apply these strategies effectively due to the severity of their symptoms.
Choice D reason:
Preparing to administer Ativan as ordered is the priority action. Ativan (lorazepam) is a benzodiazepine commonly used to treat alcohol withdrawal symptoms. It helps to prevent seizures, reduce agitation, and manage other withdrawal symptoms. During the acute phase of alcohol withdrawal, maintaining physiological stability and ensuring the client's safety are the primary concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Decreasing the dose of Xanax (alprazolam) is often necessary when a client shows signs of dependency or when there are concerns about potential side effects, such as uncontrolled hypertension. Xanax is a fast-acting benzodiazepine, which can be highly addictive, especially when taken in doses of 4 mg/day for longer than 12 weeks. It is essential to monitor the client's blood pressure and adjust the medication accordingly to avoid exacerbating hypertension.
Choice B reason:
Increasing the dose may temporarily control symptoms of anxiety, but it also increases the risk of dependency and other side effects. Given the client's uncontrolled hypertension, increasing the dose could lead to further complications.
Choice C reason:
This statement is incorrect. Xanax does cause dependency, and it is one of the most addictive benzodiazepine medications on the market today. Dependency can develop quickly, even in users who follow a prescribed dosing schedule.
Choice D reason:
While Ativan (Lorazepam) is also used to treat anxiety, adding it to the client's medication regimen without careful consideration could increase the risk of dependency and adverse effects. Both Xanax and Ativan are benzodiazepines, and their combined use should be monitored closely by a healthcare professional.
Correct Answer is A
Explanation
Choice A reason:
This statement is accurate and reflects effective teaching. Bupropion, like many antidepressants, can take several weeks to reach its full therapeutic effect. Informing patients about this delay is important to set realistic expectations and to encourage adherence to the medication regimen.
Choice B reason:
This statement is not entirely accurate. While moderate alcohol consumption may be permissible for some patients taking bupropion, it is generally advised to avoid or limit alcohol intake due to the risk of seizures and other side effects. Alcohol can also worsen depression symptoms and interact with the medication.
Choice C reason:
This statement is incorrect. Bupropion does not typically cause bradycardia (slow heartbeat). Instead, it can cause tachycardia (fast heartbeat) as a side effect. Patients should be informed about the potential cardiovascular effects of bupropion, including an increased heart rate.
Choice D reason:
This statement is incorrect. Increased salivation and drooling are not common side effects of bupropion. The medication is more commonly associated with dry mouth. Effective teaching would include informing the patient about the more likely side effects, such as dry mouth, insomnia, and headaches.
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