The nurse is preparing a client for discharge who has been taking alprazolam long-term for generalized anxiety disorder (GAD). When evaluating the client's grasp of the discharge teaching, which statement made by the client shows an understanding of the most important self-care goal?

It is essential not to abruptly discontinue taking the medication.

I should report any dizziness, lightheadedness, or sedation.

Attending individual and group therapy sessions is important.

I can report any decrease in anxiety using the 10 point scale.

Answer and Explanation

The Correct Answer is A

Choice A rationale: Abrupt discontinuation of alprazolam, a benzodiazepine used to treat anxiety disorders, can lead to withdrawal symptoms, including rebound anxiety,

insomnia, and potentially seizures. The statement reflects an understanding of the importance of gradual tapering and not abruptly stopping the medication. Choice B rationale: Reporting side effects such as dizziness, lightheadedness, or sedation is important, but the key focus for long-term benzodiazepine use is the need to avoid abrupt discontinuation.

Choice C rationale: While attending therapy sessions is beneficial for managing anxiety, the question is specifically addressing the self-care goal related to medication use. Choice D rationale: Reporting any decrease in anxiety using a 10-point scale is relevant but not as crucial as emphasizing the avoidance of abrupt discontinuation.

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Correct Answer is D

Explanation

Choice A rationale: Screening the client for domestic violence requires a more comprehensive assessment and interpretation of findings, which is beyond the scope of practice for the UAP.

Choice B rationale: Determining the client's risk for suicide involves complex judgment and should be assessed by a licensed healthcare provider, not a UAP.

Choice C rationale: Asking the client to state a chief complaint for admission involves initial communication and assessment skills, which should be performed by licensed nursing staff.

Choice D rationale: Obtaining a baseline set of vital signs is a routine task that can be delegated to the UAP. It is a non-complex and standard part of the admission process.

A. "Have you had a bad experience related to unlocked doors?" B. "What are your thoughts when you are checking the locks?" C. "Repeating the same behavior helps you to diminish your anxiety." D. "Feelings of being driven to do something are related to anxiety."

Correct Answer is B

Explanation

Choice A rationale: Asking about a bad experience may provide additional information, but it does not directly address the behavioral aspect of obsessive-compulsive disorder (OCD).

Choice B rationale: This response shows empathy and curiosity and invites the client to explore their cognitive processes behind their compulsive behavior. The nurse can help the client identify and challenge their irrational or distorted thoughts that fuel their anxiety and drive them to check the locks repeatedly.

Choice C rationale: Acknowledging that repeating the same behavior helps diminish anxiety might reinforce the client's belief that checking the locks is necessary and beneficial, which could prevent them from seeking alternative coping strategies.

Choice D rationale: Stating that feelings of being driven are related to anxiety is a general observation and may not contribute to a deeper understanding of the client's experience with OCD.

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The nurse is preparing a client for discharge who has been taking alprazolam long-term for generalized anxiety disorder (GAD). When evaluating the client's grasp of the discharge teaching, which statement made by the client shows an understanding of the most important self-care goal?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is completing an admission assessment for a client with a known history of depression and multiple, unexplained fractures. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)?

Correct Answer is D

Explanation

A client with obsessive compulsive disorder (OCD) reports feeling "driven" to check the locks on the front door at least six times every night. Which response is best for the nurse to provide?

Correct Answer is B

Explanation

The nurse interacts with a client who is very depressed and slow to respond to questions. The nurse asks the client to describe current feelings, but the client looks down at the table. Which action is best for the nurse to implement?

A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent when the client says, "I don't know how I will go on." What is the reason for the nurse's behavior?

After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy. Which action should the nurse implement?

A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client's rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?

A client who experiences memory loss is diagnosed with Wernicke encephalopathy caused by alcohol addiction. Which intervention is most important for the nurse to implement?

A 16-year-old female client is admitted to the psychiatric unit and states that she is depressed and anxious. The client appears frail and is wearing baggy clothes. When it is time for lunch, the client states, "I can't eat, I'm already overweight." What is the best response by the nurse?

When preparing to administer a domestic violence screening tool to a female client, which statement should the nurse provide?