A nurse is caring for a client who is withdrawing from a stimulant. Which of the following should be prioritized for safety in a client with stimulant withdrawal?

The client is experiencing withdrawal symptoms.

The client is experiencing hallucinations.

The client is at risk for traumatic re-experiencing.

The client is at risk for self-harm or harm to others.

Answer and Explanation

The Correct Answer is D

Choice A reason:
The client experiencing withdrawal symptoms should be monitored, as these symptoms can range from mild to severe. Withdrawal symptoms may include fatigue, depression, and anxiety, which are significant but generally not life-threatening. The nurse should provide supportive care and monitor the client's vital signs and emotional state.

Choice B reason:
If the client is experiencing hallucinations, this indicates a more severe level of withdrawal and possibly the presence of a stimulant-induced psychotic disorder. While hallucinations can be distressing and require intervention, they are not the highest priority when compared to the risk of self-harm or harm to others.

Choice C reason:
The risk for traumatic re-experiencing, or flashbacks, is a concern during withdrawal, particularly if the client has a history of trauma. These experiences can be highly distressing and may lead to further psychological distress. However, the immediate physical safety of the client and others takes precedence.

Choice D reason:
The risk of self-harm or harm to others is the most critical safety concern and must be prioritized. Clients withdrawing from stimulants may exhibit increased agitation, aggression, or impulsivity, which can lead to dangerous behaviors. The nurse must take immediate action to ensure a safe environment, which may include close supervision, the use of restraints, or rapid pharmacological intervention.

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Correct Answer is A

Explanation

Choice A Reason:
In a situation where a client has ingested a potentially lethal amount of medication, immediate medical intervention is crucial. Amitriptyline is a tricyclic antidepressant, and overdose can lead to life-threatening conditions such as cardiac arrhythmias, severe hypotension, and seizures. The nurse's priority is to ensure the safety of the client by sending an ambulance. This response also acknowledges the client's cry for help and initiates prompt action.

Choice B Reason:
While it's important to recognize the emotional state of the client, this response does not address the immediate medical emergency. The client's safety is the priority, and while their feelings are valid, this choice does not facilitate the urgent care needed.

Choice C Reason:
Asking if the client was trying to commit suicide can come across as judgmental and may close off communication. It's essential to maintain an open line of communication and focus on getting medical help rather than determining intent at this critical moment.

Choice D Reason:
Knowing the quantity of medication ingested can be useful information for medical professionals; however, it is not the most immediate concern in a crisis situation. The first response should be to ensure that medical help is on its way.

A. "It may take up to at least 2 weeks to see the effects of bupropion." B. "I can drink one glass of wine with dinner each day while taking bupropion." C. "I may develop a slow heartbeat while taking bupropion." D. "I should watch for increased salivation and drooling while taking bupropion."

Correct Answer is A

Explanation

Choice A reason:
This statement is accurate and reflects effective teaching. Bupropion, like many antidepressants, can take several weeks to reach its full therapeutic effect. Informing patients about this delay is important to set realistic expectations and to encourage adherence to the medication regimen.

Choice B reason:
This statement is not entirely accurate. While moderate alcohol consumption may be permissible for some patients taking bupropion, it is generally advised to avoid or limit alcohol intake due to the risk of seizures and other side effects. Alcohol can also worsen depression symptoms and interact with the medication.

Choice C reason:
This statement is incorrect. Bupropion does not typically cause bradycardia (slow heartbeat). Instead, it can cause tachycardia (fast heartbeat) as a side effect. Patients should be informed about the potential cardiovascular effects of bupropion, including an increased heart rate.

Choice D reason:
This statement is incorrect. Increased salivation and drooling are not common side effects of bupropion. The medication is more commonly associated with dry mouth. Effective teaching would include informing the patient about the more likely side effects, such as dry mouth, insomnia, and headaches.

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A nurse is caring for a client who is withdrawing from a stimulant. Which of the following should be prioritized for safety in a client with stimulant withdrawal?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a crisis hotline is speaking to a client who says, "I just took an entire bottle of amitriptyline." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

The nurse is evaluating teaching for a client diagnosed with depression who is prescribed bupropion (Wellbutrin). Which of the following statements made by the client indicates that the teaching was effective?

Correct Answer is A

Explanation

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