Clonidine (Catapres) is prescribed for symptoms of opioid withdrawal. Which of the following nursing assessments is essential before giving a dose of this medication?
Monitoring the client for tremors.
Determining when the client last used an opiate.
Completing a thorough physical assessment.
Assessing the client's blood pressure.
The Correct Answer is D
Choice A reason: Monitoring for tremors is important in opioid withdrawal but not the essential assessment before clonidine administration. Tremors are a symptom of withdrawal, but clonidine’s primary risk is hypotension, so blood pressure monitoring is more critical.
Choice B reason: Determining when the client last used an opiate helps in understanding withdrawal progression but does not directly influence clonidine safety. The timing of last opioid use is useful for clinical context but not the most essential assessment before giving clonidine.
Choice C reason: Completing a thorough physical assessment is a general nursing responsibility but is too broad to be considered the essential step before clonidine administration. While important, it does not specifically address the main safety concern of clonidine.
Choice D reason: Assessing blood pressure is the most essential nursing assessment before giving clonidine. Clonidine is an antihypertensive that lowers blood pressure by reducing sympathetic outflow. In opioid withdrawal, clonidine is used to reduce autonomic symptoms, but it can cause hypotension. Therefore, checking blood pressure ensures the client is safe to receive the medication and prevents complications such as severe hypotension or syncope.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:Asking if the client feels better imposes an expectation and may pressure the client to respond positively. It is not the most therapeutic approach.
Choice B reason:This assumes improvement and may invalidate the client’s actual feelings. It is not therapeutic to make assumptions about emotional state.
Choice C reason:Expressing personal happiness shifts the focus to the nurse’s feelings rather than the client’s behavior. Therapeutic communication should remain client-centered.
Choice D reason:This is correct because it is an objective, nonjudgmental observation. It acknowledges the client’s positive behavior without making assumptions or placing expectations. This type of feedback reinforces social interaction in a supportive and therapeutic manner.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason: Expressing feelings of being a burden is a strong indicator of suicidal ideation. Individuals who feel they are a burden often believe that their death would relieve others of responsibility, which increases risk. This type of statement reflects hopelessness and distorted thinking patterns commonly associated with suicidal intent.
Choice B reason: Crying when discussing sadness is an emotional expression but not necessarily a predictor of suicide risk. While it shows distress, crying is a normal coping mechanism and does not directly indicate intent to harm oneself. It is important to differentiate between emotional release and suicidal warning signs.
Choice C reason: Statements such as "everything will be better soon" can be a red flag when expressed by someone previously hopeless or depressed. This sudden optimism may reflect a decision to end their life, as they perceive suicide as a solution. Such statements often precede suicidal acts because the individual feels relief after deciding on a plan.
Choice D reason: Calling family members to make amends is a classic warning sign of suicide risk. This behavior suggests the person is preparing for death and wants to resolve unfinished business. Making amends or saying goodbye is often part of the planning process before a suicide attempt.
Choice E reason: An abrupt improvement in mood after a period of depression can be dangerous. This change may indicate that the person has resolved to commit suicide, leading to a sense of relief. Clinically, sudden mood improvement in a depressed patient should always be assessed carefully for suicidal intent.
Choice F reason: Feeling overwhelmed by simple daily tasks reflects functional impairment and depression but does not directly indicate imminent suicide risk. While it shows psychological distress, it is not as predictive of suicidal behavior as making amends, expressing burden, or sudden mood changes.
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