Flumazenil (Romazicon) has been ordered for a male A. Seizures
client who has overdosed on oxazepam (Serax). Before Rationale: Seizures are the most common adverse effect of using flumazenil to
administering the medication, the nurse should be reverse benzodiazepine overdose. The effect is magnified if the client has a
prepared for which common adverse effect? combined tricyclic antidepressant and benzodiazepine overdose. Less common
A. Seizures adverse effects includer shivering, anxiety, and chest pain.
B. Shivering
C. Anxiety
D. Chest pain
The nurse is caring for a client diagnosed with bulimia. C. Identify anxiety-causing situations
The most appropriate initial goal for a client diagnosed Rationale: Bulimic behavior is generally a maladaptive coping response to stress
with bulimia is to: and underlying issues. The client must identify anxiety-causing situation as that
A. Avoid shopping for large amounts of food stimulate the bulimic behavior and then learn new ways of coping with the
B. Control eating impulses anxiety. Controlling shopping for large amounts of food isn't a goal early in
C. Identify anxiety-causing situations treatment. Managing eating impulses and replacing them with adaptive coping
D. Eat only three meals per day mechanisms can be integrated into the plan of care after initially addressing stress
and underlying issues. Eating three meals per day isn't a realistic goal early in
treatment.
,A female client who's at high risk for suicide needs close A. Check on the client frequently at irregular intervals throughout the night
supervision. To best ensure the client's safety, the nurse Rationale: Checking the client frequently but at irregular intervals prevents the
should: client from predicting when observation will take place and altering behavior in a
A. Check on the client frequently at irregular intervals misleading way at these times. Option B may encourage the client to try to
throughout the night manipulate the nurse's or seek attention for having a secret suicide plan. Option C
B. Assure the client that the nurse will hold in confidence may reinforce a suicidal idea. Decreased communication is a sign of withdrawal
anything the client says that may indicate the client has decided to commit suicide; the nurse shouldn't
C. Repeatedly discuss previous suicide attempts with the disregard it.
client
D. Disregard decreased communication by the client
because this is common in suicidal clients
Which of the following drugs should the nurse prepare to D. acetylcysteine (Mucomyth)
administer to a client with a toxic acetaminophen Rationale: The antidote for acetaminophen toxicity is acetylcysteine. It enhances
(Tylenol) level? conversion of toxic metabolites to nontoxic metabolites. Deferoxamine meslyate
A. deferoxamine mesylate is the antidote for iron intoxication. Succimer is an antidote for lead poisoning.
B. succimer (Chemet) Flumazenil reverses the sedative effects of benzodiazepines.
C. flumazenil (Romazicon)
D. acetylcysteine (Mucomyst)
A male client is admitted to the substance abuse unit for D. clordiazepoxide (Librium)
alcohol detoxification. Which of the following Rationale: Chlordiazepoxide (Librium) and other tranquilizers help reduce the
medications is the nurse likely to administer to reduce the symptoms of alcohol withdrawal. Haloperidol (Haldol) may be given to treat
symptoms of alcohol withdrawal? clients with psychosis, severe agitation, or delirium. Naloxone (Narcan) is
A. naloxone (Narcan) administered for narcotic overdose. Magnesium sulfate and other anticonvulsant
B. haloperidol (Haldol) medications are only administer to treat seizures if they occur during the
C. magnesium sulfate withdrawal.
D. chlordiazepoxide (Librium)
, During postprandial monitor, a female client with bulimia D. "I know it's important for you to feel in control, but I'll monitor you for 90
nervosa tells the nurse, "You can sit with me, but you're minutes after you eat."
just wasting your time. After you sat with me yesterday, I Rationale: This response acknowledges that the clients is testing limits and that
was still able to purge. Today, my goal is to do it twice." the nurse is setting them by performing postprandial monitoring to prevent self-
What is the nurse's BEST responses? induced eyes is. Clients with bulimia nervosa need to feel in control of the diet
A. "I trust you not to purge." because they feel they lack control over all other aspects of their lives. Because
B. "How are you purging and when do you do it?" their therapeutic relationships with caregivers are less important than their need to
C. "Don't worry. I won't allow you to purge today." purge, they don't fear betraying the nurse's trust by engaging in the activity. They
D. "I know it's important for you to feel in control, but I'll commonly plot purging and rarely share their secrets about it. An authoritarian or
monitor you for 90 minutes after you eat." challenging response may trigger a power struggle between the nurse and client.
A male client admitted to the psychiatric unit for B. "You told me you got fired from your past job for missing too many days after
treatment of substance abuse says to the nurse, "It felt so taking drugs all night."
wonderful to get high." Which of the following is the Rationale: Confronting the client with the consequences of substance abuse helps
most appropriate response? to break through denial. Making threats (option A) isn't an effective way to
A. "If you continue to talk like that, I'm going to stop promote self-disclosure or establish a rapport with the client. Although the nurse
speaking to you." should encourage the client to discuss feelings, the discussing should focus on
B. "You told me you got fired from your past job for how the client felt before, not during, an episode of substance abuse (option C).
missing too may days after taking drugs all night." Encouraging elaboration about his experience while getting high may reinforce
C. "Tell me more about how it felt to get high." the abusive behavior. The client undoubtedly is aware that drug use is illegal; a
D. "Don't you know it's illegal to use drugs?" reminder to this effect (option D) is unlikely to alter behavior.
client who has overdosed on oxazepam (Serax). Before Rationale: Seizures are the most common adverse effect of using flumazenil to
administering the medication, the nurse should be reverse benzodiazepine overdose. The effect is magnified if the client has a
prepared for which common adverse effect? combined tricyclic antidepressant and benzodiazepine overdose. Less common
A. Seizures adverse effects includer shivering, anxiety, and chest pain.
B. Shivering
C. Anxiety
D. Chest pain
The nurse is caring for a client diagnosed with bulimia. C. Identify anxiety-causing situations
The most appropriate initial goal for a client diagnosed Rationale: Bulimic behavior is generally a maladaptive coping response to stress
with bulimia is to: and underlying issues. The client must identify anxiety-causing situation as that
A. Avoid shopping for large amounts of food stimulate the bulimic behavior and then learn new ways of coping with the
B. Control eating impulses anxiety. Controlling shopping for large amounts of food isn't a goal early in
C. Identify anxiety-causing situations treatment. Managing eating impulses and replacing them with adaptive coping
D. Eat only three meals per day mechanisms can be integrated into the plan of care after initially addressing stress
and underlying issues. Eating three meals per day isn't a realistic goal early in
treatment.
,A female client who's at high risk for suicide needs close A. Check on the client frequently at irregular intervals throughout the night
supervision. To best ensure the client's safety, the nurse Rationale: Checking the client frequently but at irregular intervals prevents the
should: client from predicting when observation will take place and altering behavior in a
A. Check on the client frequently at irregular intervals misleading way at these times. Option B may encourage the client to try to
throughout the night manipulate the nurse's or seek attention for having a secret suicide plan. Option C
B. Assure the client that the nurse will hold in confidence may reinforce a suicidal idea. Decreased communication is a sign of withdrawal
anything the client says that may indicate the client has decided to commit suicide; the nurse shouldn't
C. Repeatedly discuss previous suicide attempts with the disregard it.
client
D. Disregard decreased communication by the client
because this is common in suicidal clients
Which of the following drugs should the nurse prepare to D. acetylcysteine (Mucomyth)
administer to a client with a toxic acetaminophen Rationale: The antidote for acetaminophen toxicity is acetylcysteine. It enhances
(Tylenol) level? conversion of toxic metabolites to nontoxic metabolites. Deferoxamine meslyate
A. deferoxamine mesylate is the antidote for iron intoxication. Succimer is an antidote for lead poisoning.
B. succimer (Chemet) Flumazenil reverses the sedative effects of benzodiazepines.
C. flumazenil (Romazicon)
D. acetylcysteine (Mucomyst)
A male client is admitted to the substance abuse unit for D. clordiazepoxide (Librium)
alcohol detoxification. Which of the following Rationale: Chlordiazepoxide (Librium) and other tranquilizers help reduce the
medications is the nurse likely to administer to reduce the symptoms of alcohol withdrawal. Haloperidol (Haldol) may be given to treat
symptoms of alcohol withdrawal? clients with psychosis, severe agitation, or delirium. Naloxone (Narcan) is
A. naloxone (Narcan) administered for narcotic overdose. Magnesium sulfate and other anticonvulsant
B. haloperidol (Haldol) medications are only administer to treat seizures if they occur during the
C. magnesium sulfate withdrawal.
D. chlordiazepoxide (Librium)
, During postprandial monitor, a female client with bulimia D. "I know it's important for you to feel in control, but I'll monitor you for 90
nervosa tells the nurse, "You can sit with me, but you're minutes after you eat."
just wasting your time. After you sat with me yesterday, I Rationale: This response acknowledges that the clients is testing limits and that
was still able to purge. Today, my goal is to do it twice." the nurse is setting them by performing postprandial monitoring to prevent self-
What is the nurse's BEST responses? induced eyes is. Clients with bulimia nervosa need to feel in control of the diet
A. "I trust you not to purge." because they feel they lack control over all other aspects of their lives. Because
B. "How are you purging and when do you do it?" their therapeutic relationships with caregivers are less important than their need to
C. "Don't worry. I won't allow you to purge today." purge, they don't fear betraying the nurse's trust by engaging in the activity. They
D. "I know it's important for you to feel in control, but I'll commonly plot purging and rarely share their secrets about it. An authoritarian or
monitor you for 90 minutes after you eat." challenging response may trigger a power struggle between the nurse and client.
A male client admitted to the psychiatric unit for B. "You told me you got fired from your past job for missing too many days after
treatment of substance abuse says to the nurse, "It felt so taking drugs all night."
wonderful to get high." Which of the following is the Rationale: Confronting the client with the consequences of substance abuse helps
most appropriate response? to break through denial. Making threats (option A) isn't an effective way to
A. "If you continue to talk like that, I'm going to stop promote self-disclosure or establish a rapport with the client. Although the nurse
speaking to you." should encourage the client to discuss feelings, the discussing should focus on
B. "You told me you got fired from your past job for how the client felt before, not during, an episode of substance abuse (option C).
missing too may days after taking drugs all night." Encouraging elaboration about his experience while getting high may reinforce
C. "Tell me more about how it felt to get high." the abusive behavior. The client undoubtedly is aware that drug use is illegal; a
D. "Don't you know it's illegal to use drugs?" reminder to this effect (option D) is unlikely to alter behavior.
