A client experiencing withdrawal from the benzodiazepine alprazolam is demonstrating severe agitation and tremors. Which is the best initial nursing action?

Instruct the family about withdrawal symptoms.

Initiate seizure precautions.

Obtain a serum drug screen.

Administer naloxone per PRN protocol.

Answer and Explanation

The Correct Answer is B

A. Instruct the family about withdrawal symptoms. While educating the family about withdrawal symptoms is important for support and understanding, it is not the best initial action when the
client is experiencing severe agitation and tremors. Safety measures should be prioritized.

B.   Initiate seizure precautions. Severe agitation and tremors can be signs of benzodiazepine withdrawal, which may progress to seizures. Initiating seizure precautions, such as ensuring a
safe environment, padding side rails, and having emergency medications and equipment readily available, is the priority to prevent injury.
C.   Obtain a serum drug screen. While obtaining a serum drug screen may be necessary to confirm benzodiazepine withdrawal, it is not the immediate action needed to address the client's current symptoms and prevent potential harm.
D.   Administer naloxone per PRN protocol. Naloxone is an opioid antagonist used to reverse opioid overdose and is not indicated for benzodiazepine withdrawal. Administering naloxone would not be appropriate or effective in this situation.

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Correct Answer is C

Explanation

A. Right ear hearing loss. While significant, right ear hearing loss is not immediately life- threatening.
B. Difficulty with balance. Balance issues may be concerning but are not typically indicative of a life-threatening condition.
C. Intensifying headache. An intensifying headache can be a sign of increased intracranial pressure, which is a medical emergency and requires immediate attention.
D. Facial numbness. Facial numbness can indicate nerve involvement but is not as immediately concerning as an intensifying headache, which could indicate a serious neurological issue such as bleeding or swelling in the brain.

A. Gastric Irritation. B. Moon facies. C. Abdominal striae. D. Rapid weight gain.

Correct Answer is D

Explanation

A. Gastric Irritation.

While gastric irritation is a common side effect of prednisone, it is not as critical as some other potential adverse effects and can often be managed with medication or dietary changes.

B. Moon facies.

Moon facies is a sign of Cushing's syndrome, a potential long-term side effect of prednisone, but it does not require immediate reporting compared to more acute symptoms.

C. Abdominal striae.
Abdominal striae (stretch marks) are a long-term side effect of corticosteroids like prednisone, but they are not typically an urgent concern.

D. Rapid weight gain.

This is the correct answer because rapid weight gain can indicate fluid retention, which may be a sign of more serious side effects such as heart failure or severe hypertension. It requires prompt medical attention to prevent further complications.

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A client experiencing withdrawal from the benzodiazepine alprazolam is demonstrating severe agitation and tremors. Which is the best initial nursing action?

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