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Flumazenil (Romazicon) has been ordered for a male client who has overdosed on
oxazepam (Serax). Before administering the medication, the nurse should be
prepared for which common adverse effect?
A. Seizures
B. Shivering
C. Anxiety
D. Chest pain - Answer-A. Seizures
Rationale: Seizures are the most common adverse effect of using flumazenil to
reverse benzodiazepine overdose. The effect is magnified if the client has a
combined tricyclic antidepressant and benzodiazepine overdose. Less common
adverse effects includer shivering, anxiety, and chest pain.
The nurse is caring for a client diagnosed with bulimia. The most appropriate
initial goal for a client diagnosed with bulimia is to:
A. Avoid shopping for large amounts of food
B. Control eating impulses
C. Identify anxiety-causing situations
D. Eat only three meals per day - Answer-C. Identify anxiety-causing situations
Rationale: Bulimic behavior is generally a maladaptive coping response to stress
and underlying issues. The client must identify anxiety-causing situation as that
,stimulate the bulimic behavior and then learn new ways of coping with the
anxiety. Controlling shopping for large amounts of food isn't a goal early in
treatment. Managing eating impulses and replacing them with adaptive coping
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.
The nurse is caring for a client being treated for alcoholism. Before initiating
therapy with disulfiram (Antabuse), the nurse teaches the client that he must
read labels carefully on which of the following products?
A. Carbonated beverages
B. Aftershave lotion
C. Toothpaste
D. Cheese - Answer-B. Aftershave lotion
Rationale: Disulfiram may be given to client with chronic alcohol abuse who wish
to curb impulse drinking. Disulfiram works by blocking the oxidation of alcohol,
inhibiting the conversion of acetaldehyde to acetate. As acetaldehyde builds up in
the blood, the client experiences noxious and uncomfortable symptoms. Even
alcohol rubbed onto the skin can product a reaction. The client receiving
disulfiram must be taught to read ingredient labels carefully to avoid products
containing alcohol such as aftershave lotions. Carbonated beverages, toothpaste,
and cheese don't contain alcohol and don't need to be avoided by the client.
The nurse is developing a plan of care for a client with anorexia nervosa. Which
action should the nurse include in the plan?
A. Restrict visits with the family until the client begins to eat
B. Provide privacy during meals
C. Set up a strict eating plan for the client
, D. Encourage the client to exercise, which will reduce her anxiety - Answer-C. Set
up a strict eating plan for the client
Rationale: Establishing a consistent eating plan and monitoring the client's weight
are important for this disorder. The family should be included in the client's care.
The client should be monitored during meals - not given privacy. Exercise should
be limited and supervised.
The nurse is aware that the victims of domestic violence should be assessed for
what important information?
A. Reasons they stay in the abusive relationships (for example, lack of financial
autonomy and isolation)
B. Readiness to leave the perpetrator and knowledge of resources
C. Use of drugs or alcohol
D. History of previous victimization - Answer-B. Readiness to leave the
perpetrator and knowledge or resources
Rationale: Victims of domestic violence must be assessed for their readiness to
leave the perpetrator and their knowledge of resources available to them. Nurses
can then provide the victims with information and options to enable them to
leave when they are ready. The reasons they stay in the relationship are complex
and can be explored at a later time. The use of drugs or alcohol is irrelevant.
There is no evidence to suggest that previous victimization results in person's
seeking or causing abusive relationships.
A male client is hospitalized with fractures of the right femur and right humerus
sustained in a motorcycle accident. Police suspect the client was intoxicated at
the time of the accident. Laboratory tests reveal a blood alcohol level of 0.2%
(200 mg/dL). The client later admits to drinking heavily for years. During
hospitalization, the client periodically complains of tingling and numbness in the
hands and feet. The nurse realizes that these symptoms probably result from:
A. Acetate accumulation