The nurse is caring for a client who has been the victim of intimate partner violence. During the interview, the nurse feels angry, embarrassed, and helpless. Which explanation best describes the cause of the nurse’s emotions?

Subconscious blame toward the client for staying in an abusive relationship.

Difficulty accepting the explanation about how the injuries actually occurred.

Experience in caring for clients who are affected by family violence is limited.

Feelings are influencing the client’s care due to a personal history of abuse.

Answer and Explanation

The Correct Answer is A

A.   Feeling angry, embarrassed, and helpless may indicate subconscious blame or judgment toward the client for staying in an abusive relationship. It's important for the nurse to recognize and address these feelings to provide non-judgmental and supportive care.
B.   Difficulty accepting the explanation about how the injuries occurred could contribute to these feelings, but it is not the primary cause in this context.
C. Limited experience in caring for clients affected by family violence may contribute to discomfort, but it does not explain the specific emotions described.
D.   While a personal history of abuse could impact the nurse's feelings, the question is asking for the immediate cause of the emotions during the current interaction with the client.

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Correct Answer is D

Explanation

A. Using relaxation techniques is a positive and appropriate strategy for managing anxiety.
B. Avoiding alcohol and other sedatives is essential as they can potentiate the sedative effects of lorazepam.
C. Moving slowly from a sitting to a standing position is important to minimize orthostatic hypotension, a potential side effect of lorazepam.
D. Stopping the medication if the intended effect is not immediate is not appropriate guidance.
Lorazepam, like many benzodiazepines, may take some time to achieve its full therapeutic effect. Abrupt discontinuation can lead to withdrawal symptoms and should be done under the guidance of a healthcare provider.

A. Determine the client’s reason for attempting suicide. B. Obtain the client’s serum hydrocodone/acetaminophen level. C. Encourage the client to increase fluid intake. D. Observe the client for further narcotic effects.

Correct Answer is D

Explanation

A. Determine the client’s reason for attempting suicide: While assessing suicidal intent is important, the immediate priority is ensuring the client's physiological stability. Suicidal ideation can be addressed once the client is medically stable.

B. Obtain the client’s serum hydrocodone/acetaminophen level: This may be ordered, but it is not the highest priority. Clinical observation is more urgent, especially because naloxone has a shorter half-life than many opioids, including hydrocodone.

C. Encourage the client to increase fluid intake: This is not a priority intervention in the immediate post-overdose period and does not address the risk of opioid rebound toxicity.

D. Observe the client for further narcotic effects: Naloxone has a short duration of action (typically 30–90 minutes), whereas hydrocodone has a longer half-life. Once naloxone wears off, respiratory depression and sedation can recur. Continuous monitoring is critical to ensure timely re-administration if opioid effects return.

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The nurse is caring for a client who has been the victim of intimate partner violence. During the interview, the nurse feels angry, embarrassed, and helpless. Which explanation best describes the cause of the nurse’s emotions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with generalized anxiety disorder (GAD) receives a new prescription for lorazepam. Which statement provided by the client requires additional instruction by the nurse?

Correct Answer is D

Explanation

Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?

Correct Answer is D

Explanation

A homeless female client who reports feeling sad and depressed tells the mental health nurse that in the past two days, the client has only had four hours of sleep. Which action is most important for the nurse to implement within the first 24 hours after treatment is initiated?

A client diagnosed with schizophrenia has been receiving haloperidol for the past year, and the treatment plan includes moving the client to a lower maintenance dosage. Which intervention should the nurse include in this client’s plan of care? (Select all that apply)

A client with chronic alcohol dependency is admitted due to a recent relapse. Which findings should the nurse expect this client to exhibit? (Select all that apply)

Which individual should the nurse consider at the highest risk for suicide?

During a high school substance abuse class, a student tells the group, “I know that marijuana is not addicting, so why shouldn’t I use it? Which response is best for the nurse to provide?

While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client’s tongue is “worming”. The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain?