A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following medications should the
nurse prepare to administer?
a. Carbamazepine
b. Clonidine
c. Propranolol
d. Lorazepam
D
The nurse should expect to administer lorazepam, a benzodiazepine, as the first treatment for acute alcohol withdrawal.
Along with decreasing symptoms of acute alcohol withdrawal, these medications can also maintain vital signs and prevent
seizures and delirium tremens.
Incorrect Answers:
A. Carbamazepine is an antiepileptic medication that can be used with a benzodiazepine for acute alcohol withdrawal.
However, benzodiazepines such as lorazepam are the first choice for acute alcohol withdrawal.
B. Clonidine is a central alpha-adrenergic agonist medication that can be used with a benzodiazepine for acute alcohol
withdrawal. However, benzodiazepines are the first choice for acute alcohol withdrawal.
C. Propranolol is a beta-adrenergic blocker medication that can be used with a benzodiazepine for acute alcohol withdrawal.
However, benzodiazepines are the first choice for acute alcohol withdrawal. Many clients who have alcohol use disorder
have poor diets, which renders them malnourished. Because of this poor nutritional state, these clients need foods with a
high nutritional value such as fat and protein. This can be achieved through dietary modification, not fluid-replacement
therapy
,A nurse is caring for a client with obsessive-compulsive disorder (OCD) who has been taking fluoxetine for 3 months. The
client states, "This medication isn't working. I want to stop taking it." Which of the following responses should the nurse
make?
A. "It is best to discontinue the medication slowly over 1 or 2 months."
B. "If the medication hasn't helped you in 3 months, it's not going to."
C. "You will likely gain weight if you stop taking the medication."
D. "This medication is the only treatment available for your condition."
A
The nurse should respond by telling the client that withdrawing from the medication should be done slowly to reduce any
manifestations of withdrawal. This can be achieved by reducing the dosage by 25% every 1 to 2 months.
Incorrect Answers:
B. The nurse should respond by telling the client that the effects of fluoxetine take several months to peak and that therapy
should continue for a year before discontinuation.
C. The nurse should not indicate that weight gain is likely with the withdrawal of fluoxetine. An adverse effect of taking the
medication is weight gain.
D. The nurse should not indicate that fluoxetine is the only treatment for OCD. Other SSRI medications are effective for the
disorder. Some clients benefit from behavioral therapy and deep-brain stimulation.
,A nurse is assessing a client who has major depressive disorder. Which of the following questions should the nurse prioritize
when speaking with the client?
A. "Do you have any close friends?"
B. "Can you describe how you feel about what's happening?"
C. "Have you thought about hurting yourself?"
D. "How are you dealing with being away from your family?"
C
The greatest risk to the client at this time is suicide. Therefore, the priority question the nurse should ask is if the client has
any intent to self-harm.
Incorrect Answers:
A. Exploring the client's interpersonal relationships is an intervention the nurse should perform to help develop a therapeutic
relationship. However, another question is the nurse's priority at this time.
B. Asking about how the client feels is an ongoing intervention that can help the nurse develop and strengthen the
therapeutic relationship. However, another question is the nurse's priority at this time.
D. Asking how the client is dealing with being in the hospital and away from family is an ongoing intervention that can help
the nurse develop and strengthen the therapeutic relationship. However, another question is the nurse's priority at this time.
, A nurse in a mental health clinic is caring for a client who states, "I think I might have a problem with alcohol." Which of
the following actions should the nurse take first?
A. Provide the client with information about a 12-step recovery program
B. Encourage the client to accept responsibility for his alcohol use
C. Teach the client alternate coping mechanisms to use in place of alcohol
D. Ask the client to complete the CAGE questionnaire
D
The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions.
Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the
nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's
status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the
nurse with the knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to assess the
client's alcohol use. Completing a CAGE questionnaire can help determine the impact of alcohol use on the client's life.
Incorrect
Answers:
A. The nurse should provide the client with information about a 12-step recovery program, such as Alcoholics Anonymous;
however, there is another action that the nurse should take first.
B. The nurse should encourage the client to accept responsibility for his alcohol use, which encourages acceptance of the
alcohol use problem and promotes recovery; however, there is another action that the nurse should take first.
C. The nurse should teach the client coping mechanisms to use in response to stress besides alcohol; however, there is
another action that the nurse should take first
nurse prepare to administer?
a. Carbamazepine
b. Clonidine
c. Propranolol
d. Lorazepam
D
The nurse should expect to administer lorazepam, a benzodiazepine, as the first treatment for acute alcohol withdrawal.
Along with decreasing symptoms of acute alcohol withdrawal, these medications can also maintain vital signs and prevent
seizures and delirium tremens.
Incorrect Answers:
A. Carbamazepine is an antiepileptic medication that can be used with a benzodiazepine for acute alcohol withdrawal.
However, benzodiazepines such as lorazepam are the first choice for acute alcohol withdrawal.
B. Clonidine is a central alpha-adrenergic agonist medication that can be used with a benzodiazepine for acute alcohol
withdrawal. However, benzodiazepines are the first choice for acute alcohol withdrawal.
C. Propranolol is a beta-adrenergic blocker medication that can be used with a benzodiazepine for acute alcohol withdrawal.
However, benzodiazepines are the first choice for acute alcohol withdrawal. Many clients who have alcohol use disorder
have poor diets, which renders them malnourished. Because of this poor nutritional state, these clients need foods with a
high nutritional value such as fat and protein. This can be achieved through dietary modification, not fluid-replacement
therapy
,A nurse is caring for a client with obsessive-compulsive disorder (OCD) who has been taking fluoxetine for 3 months. The
client states, "This medication isn't working. I want to stop taking it." Which of the following responses should the nurse
make?
A. "It is best to discontinue the medication slowly over 1 or 2 months."
B. "If the medication hasn't helped you in 3 months, it's not going to."
C. "You will likely gain weight if you stop taking the medication."
D. "This medication is the only treatment available for your condition."
A
The nurse should respond by telling the client that withdrawing from the medication should be done slowly to reduce any
manifestations of withdrawal. This can be achieved by reducing the dosage by 25% every 1 to 2 months.
Incorrect Answers:
B. The nurse should respond by telling the client that the effects of fluoxetine take several months to peak and that therapy
should continue for a year before discontinuation.
C. The nurse should not indicate that weight gain is likely with the withdrawal of fluoxetine. An adverse effect of taking the
medication is weight gain.
D. The nurse should not indicate that fluoxetine is the only treatment for OCD. Other SSRI medications are effective for the
disorder. Some clients benefit from behavioral therapy and deep-brain stimulation.
,A nurse is assessing a client who has major depressive disorder. Which of the following questions should the nurse prioritize
when speaking with the client?
A. "Do you have any close friends?"
B. "Can you describe how you feel about what's happening?"
C. "Have you thought about hurting yourself?"
D. "How are you dealing with being away from your family?"
C
The greatest risk to the client at this time is suicide. Therefore, the priority question the nurse should ask is if the client has
any intent to self-harm.
Incorrect Answers:
A. Exploring the client's interpersonal relationships is an intervention the nurse should perform to help develop a therapeutic
relationship. However, another question is the nurse's priority at this time.
B. Asking about how the client feels is an ongoing intervention that can help the nurse develop and strengthen the
therapeutic relationship. However, another question is the nurse's priority at this time.
D. Asking how the client is dealing with being in the hospital and away from family is an ongoing intervention that can help
the nurse develop and strengthen the therapeutic relationship. However, another question is the nurse's priority at this time.
, A nurse in a mental health clinic is caring for a client who states, "I think I might have a problem with alcohol." Which of
the following actions should the nurse take first?
A. Provide the client with information about a 12-step recovery program
B. Encourage the client to accept responsibility for his alcohol use
C. Teach the client alternate coping mechanisms to use in place of alcohol
D. Ask the client to complete the CAGE questionnaire
D
The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions.
Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the
nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's
status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the
nurse with the knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to assess the
client's alcohol use. Completing a CAGE questionnaire can help determine the impact of alcohol use on the client's life.
Incorrect
Answers:
A. The nurse should provide the client with information about a 12-step recovery program, such as Alcoholics Anonymous;
however, there is another action that the nurse should take first.
B. The nurse should encourage the client to accept responsibility for his alcohol use, which encourages acceptance of the
alcohol use problem and promotes recovery; however, there is another action that the nurse should take first.
C. The nurse should teach the client coping mechanisms to use in response to stress besides alcohol; however, there is
another action that the nurse should take first
