The nurse is continuing to care for the client in the emergency department (ED).
The nurse should monitor the client for which of the following based on the result of the client's laboratory test? Select all that apply.
Amnesia
Nausea and vomiting
Hyperthermia
Tachycardia
Respiratory depression
Combativeness
Correct Answer : A,B,E
Rationale for correct choices:
- Amnesia: GHB is known to cause memory loss or amnesia, particularly retrograde amnesia, which makes the client unable to recall events that occurred during intoxication. This is a common effect of GHB when it is used as a "date rape drug."
- Nausea and vomiting: GHB can cause gastrointestinal symptoms, including nausea and vomiting. This is a well-known side effect, especially when the drug is ingested in larger quantities or in combination with alcohol.
- Respiratory depression: One of the most concerning effects of GHB is respiratory depression. This can be life-threatening, as GHB has a sedative effect on the central nervous system, potentially leading to slow or shallow breathing and, in extreme cases, respiratory failure.
Rationale for incorrect choices:
- Hyperthermia: GHB typically causes sedation and hypothermia rather than hyperthermia. While stimulant drugs (e.g., methamphetamine) can lead to increased body temperature, GHB is more commonly associated with decreased body temperature.
- Tachycardia: GHB does not typically cause tachycardia. It is more likely to cause bradycardia (slower heart rate) or maintain normal heart rates due to its sedative effects.
- Combativeness: GHB is a sedative and CNS depressant, not a stimulant. Therefore, it is unlikely to cause combativeness, which is more typically associated with stimulant drugs like cocaine or methamphetamine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Dwelling on these struggles will not help you move past your loss.": This response dismisses the client’s feelings and may minimize their grief. Acknowledging their emotions is important for therapeutic communication, and telling the client to stop dwelling may feel invalidating.
B. "Everyone struggles with loss, but you'll be okay in time.": While this response is intended to offer comfort, it may sound dismissive and could undermine the client’s grief experience. Each person processes loss differently, and it's important to acknowledge their feelings.
C. "Attending a support group may help both you and your partner.": This response is supportive and practical. It acknowledges that grief affects both individuals in a relationship and suggests a helpful resource. Support groups provide validation and connection with others going through similar experiences.
D. "Spend more time focusing on your relationship with your partner.": This response oversimplifies the situation and does not acknowledge the depth of the client’s grief. It may feel directive and might not address the underlying emotional need.
Correct Answer is B
Explanation
A. Encourage the client to reframe their perception of stress: Reframing can be a helpful strategy for less severe anxiety, but during a panic attack, the client may be too overwhelmed to engage in cognitive techniques like reframing. Immediate support is needed first.
B. Guide the client to a location that is quiet and stay with the client: This is the best intervention. A quiet environment helps reduce external stimuli, and staying with the client provides reassurance and safety, helping to calm the overwhelming anxiety during a panic attack.
C. Help the client identify factors that are contributing to the anxiety: While identifying triggers is important for long-term management, during a panic attack, the priority is immediate relief and safety. The client may not be able to engage in reflection during peak anxiety.
D. Ask questions to clarify how the client feels and what they are thinking: During a panic attack, the client is likely to be too overwhelmed to respond meaningfully to questions. The priority is to offer comfort and a calm presence rather than focusing on understanding their thoughts at that moment.
Complete the following sentence by using the lists of options.
The client is at risk of developing