What should the nurse plan to teach as a priority for a client who is taking a benzodiazepine daily for anxiety?

The potential for dependence and tolerance

It should be taken first thing in the morning with food

The importance of discontinuing immediately if addiction is suspected

Increased caffeine consumption will increase the effectiveness

Answer and Explanation

The Correct Answer is A

Choice A reason: Benzodiazepines enhance GABA activity, leading to rapid anxiety relief but with a high risk of tolerance and dependence. Teaching about this risk is critical to ensure the client understands the need for medical supervision, potential withdrawal symptoms, and strategies to prevent misuse or long-term dependency.

Choice B reason: Taking benzodiazepines with food may reduce gastrointestinal upset, but the timing is not critical for efficacy. This instruction is less urgent than addressing dependence, as benzodiazepines are effective regardless of meal timing, and the primary concern is their addictive potential.

Choice C reason: Discontinuing benzodiazepines abruptly can cause severe withdrawal symptoms, including seizures, due to their effect on GABA receptors. This is dangerous advice, as gradual tapering under medical supervision is required, making this choice incorrect and less critical than teaching about dependence risks.

Choice D reason: Increased caffeine consumption can counteract benzodiazepine effects by stimulating the central nervous system, potentially worsening anxiety. This is incorrect advice, as it could reduce the medication’s efficacy and exacerbate symptoms, making it less relevant than educating about dependence and tolerance risks.

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Correct Answer is C

Explanation

Choice A reason: Furosemide is a diuretic used for fluid overload in heart failure, not for second-degree AV block Type II, which causes bradycardia and hypotension. Administering it could worsen hypotension by reducing preload, making it inappropriate for this client’s acute conduction issue.

Choice B reason: Thrombolytic medications are used for acute myocardial infarction or stroke to dissolve clots. Second-degree AV block Type II is a conduction disorder, not a thrombotic event, so thrombolytics are irrelevant and could cause harmful bleeding in this scenario.

Choice C reason: Second-degree AV block Type II causes intermittent failure of atrial impulses to conduct, leading to bradycardia and hypotension. Transcutaneous pacing restores heart rate and cardiac output, stabilizing the client’s hemodynamics, making it the most appropriate intervention for this life-threatening rhythm disturbance.

Choice D reason: Synchronized cardioversion is used for tachyarrhythmias like atrial fibrillation or ventricular tachycardia. Second-degree AV block Type II is a bradyarrhythmia, so cardioversion is inappropriate. Pacing is needed to increase heart rate and address the client’s symptoms effectively.

A. Assessment of family health history B. Assessment of the client’s knowledge of treatment options C. Assessment of early disturbance in family interactions D. Assessment and monitoring of vital signs and lab values

Correct Answer is D

Explanation

Choice A reason: Assessing family health history may provide context for genetic predispositions to mental health disorders. However, it is not the priority upon admission, as it does not address immediate physiological risks like malnutrition or cardiac instability, which are critical in anorexia nervosa due to severe weight loss.

Choice B reason: Assessing the client’s knowledge of treatment options is important for engaging them in their care plan. However, this is secondary to addressing immediate physical health risks, such as electrolyte imbalances or cardiac complications, which are life-threatening in anorexia nervosa and require urgent attention.

Choice C reason: Assessing early disturbances in family interactions may help identify triggers for anorexia nervosa, such as emotional stress. However, this is not the priority upon admission, as it does not address the immediate physiological dangers of malnutrition, dehydration, or organ dysfunction, which take precedence.

Choice D reason: Anorexia nervosa can cause severe physiological complications, including bradycardia, hypotension, and electrolyte imbalances, due to malnutrition. Assessing and monitoring vital signs and lab values is critical to identify life-threatening conditions like hypokalemia or cardiac arrhythmias, ensuring immediate stabilization and guiding treatment, making it the priority intervention.

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What should the nurse plan to teach as a priority for a client who is taking a benzodiazepine daily for anxiety?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client diagnosed with anorexia nervosa is newly admitted to an inpatient psychiatric unit. Which nursing intervention takes priority?

Correct Answer is D

Explanation

A client notifies a treatment team member of current suicidal ideation. Which nursing intervention would take priority?

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What should the nurse plan to teach as a priority for a client who is taking a benzodiazepine daily for anxiety?

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