Which statement best documents the situation when a client becomes extremely agitated after receiving a sedative?

An idiosyncratic drug effect.

A toxic drug effect.

An allergic drug response.

An unexpected drug interaction.

Answer and Explanation

The Correct Answer is A

An idiosyncratic drug effect is an unpredictable and uncommon reaction to a drug that is not related to the dose, the pharmacology, or the patient’s allergy or intolerance. It may be caused by genetic factors, metabolic abnormalities, or interactions with other drugs or substances. An example of an idiosyncratic drug effect is paradoxical agitation or excitement after receiving a sedative.

B. A toxic drug effect is a harmful reaction to a drug that is related to the dose or the pharmacology of the drug. It may cause symptoms such as nausea, vomiting, drowsiness, confusion, or respiratory depression. A toxic drug effect is unlikely to cause agitation after receiving a sedative unless there is an overdose or a drug interaction that increases the level of the sedative in the blood.

C. An allergic drug response is an immunological reaction to a drug that is not related to the dose or the pharmacology of the drug. It may cause symptoms such as rash, itching, swelling, fever, or anaphylaxis. An allergic drug response is unlikely to cause agitation after receiving a sedative unless there is a severe anaphylactic reaction that affects the brain or the circulation.

D. An unexpected drug interaction is a modification of the effect of one drug by another drug or substance that is not predictable based on their pharmacology. It may cause an increase or a decrease in the efficacy or toxicity of one or both drugs. An unexpected drug interaction may cause agitation after receiving a sedative if there is a synergistic effect that enhances the central nervous system stimulation of another drug or substance (such as caffeine, cocaine, or amphetamines) or if there is an antagonistic effect that reduces the central nervous system depression of the sedative (such as flumazenil, naloxone, or physostigmine). However, these interactions are usually known and avoidable by checking the patient’s history and medication list.

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Correct Answer is C

Explanation

This is the priority action because it follows the RACE acronym for fire safety: Rescue, Alarm, Contain, Extinguish. The nurse should first rescue the client from immediate danger by smothering the flames with a blanket.

This will also help contain the fire and prevent it from spreading.

Choice A is wrong because closing the window and removing the client’s oxygen will not put out the fire.

Oxygen is not flammable, but it can make a fire burn faster and hotter. Removing the oxygen source may help reduce the intensity of the fire, but it will not extinguish it.

Choice B is wrong because sounding the fire alarm and activating the emergency response system are important steps, but they are not the priority. The nurse should first ensure the client’s safety before alerting others and calling for help.

Choice D is wrong because removing the client from the room and closing the door may expose the client to more harm and make the fire worse.

The nurse should not move the client unless it is absolutely necessary, as this may cause further injury or infection. Closing the door may create a backdraft, which is a sudden explosion of fire caused by oxygen rushing into an enclosed space.

A. “I don’t want to know this. Tell your health care provider.”. B. “I’m your nurse and you can tell me anything.”. C. “I’ll close the door first so that no one will hear you.”. D. “I can’t promise that the information won’t be shared if your health or safety is involved.”.

Correct Answer is D

Explanation

“I can’t promise that the information won’t be shared if your health or safety is involved.” This response by the nurse would be appropriate because it respects the client’s confidentiality while also acknowledging its limits of it. The nurse has a duty to report any information that may indicate a risk of harm to the client or others.

Choice A is wrong because it dismisses the client’s need to share something and implies that the nurse is not interested or trustworthy.

Choice B is wrong because it gives a false assurance of confidentiality and may lead to ethical dilemmas if the client reveals something that requires reporting.

Choice C is wrong because it does not address the issue of confidentiality and may give the impression that the nurse is trying to avoid the conversation.

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Which statement best documents the situation when a client becomes extremely agitated after receiving a sedative?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse enters a client’s room and finds the client’s gown is on fire. Which is the nurse’s priority action?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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