Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is teaching a female client who has an anxiety disorder and is prescribed alprazolam (Xanax). Which of the following information should the nurse include in the teaching?
A. "If a dose is missed, double the next dose of medication."
“If a dose is missed, double the next dose of medication.” This statement is incorrect. Doubling up on a dose can lead to an overdose and serious side effects. Patients are advised to take the missed dose as soon as they remember unless it’s almost time for the next dose.
B. "This medication may increase your blood pressure."
“This medication may increase your blood pressure.” Alprazolam is known to have a sedative effect, which can lower blood pressure rather than increase it. Therefore, this statement is not typically accurate.
C. "Do not eat aged cheeses while taking this medication."
“Do not eat aged cheeses while taking this medication.” This dietary restriction is associated with monoamine oxidase inhibitors (MAOIs), which are a different class of medications used to treat depression. Alprazolam does not interact with tyramine-rich foods like aged cheeses, so this statement is not applicable.
D. "Use a dependable form of contraception while taking this medication.”
“Use a dependable form of contraception while taking this medication.” Alprazolam falls under FDA Pregnancy Category D, which means there is positive evidence of human fetal risk, but the potential benefits may warrant use in pregnant women despite the risks. Therefore, it is important to use reliable contraception to prevent pregnancy while taking this medication.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom NSG 133 Mental Health Final Proctored Exam Summer (2023). Take the full exam now
Full Explanation
The correct answer is D:
Choice A reason: “If a dose is missed, double the next dose of medication.” This statement is incorrect. Doubling up on a dose can lead to an overdose and serious side effects. Patients are advised to take the missed dose as soon as they remember unless it’s almost time for the next dose.
Choice B reason: “This medication may increase your blood pressure.” Alprazolam is known to have a sedative effect, which can lower blood pressure rather than increase it. Therefore, this statement is not typically accurate.
Choice C reason: “Do not eat aged cheeses while taking this medication.” This dietary restriction is associated with monoamine oxidase inhibitors (MAOIs), which are a different class of medications used to treat depression. Alprazolam does not interact with tyramine-rich foods like aged cheeses, so this statement is not applicable.
Choice D reason: “Use a dependable form of contraception while taking this medication.” Alprazolam falls under FDA Pregnancy Category D, which means there is positive evidence of human fetal risk, but the potential benefits may warrant use in pregnant women despite the risks. Therefore, it is important to use reliable contraception to prevent pregnancy while taking this medication.
Similar Questions
Exhibit. The spouse of a male client with early-stage Alzheimer's disease (AD) tells the nurse, "I am just exhausted from the constant worry. I don't know what to do." Which action is best for the nurse to take next? (Select All That Apply.)
A. Suggest that a long-term care facility be considered.
Suggesting a long-term care facility should not be the first action. Early-stage Alzheimer's clients can often remain at home with proper support, and suggesting institutionalization might not be appropriate at this stage.
B. Offer ideas for ways to distract or redirect the client.
This is a correct choice. Engaging the client with Alzheimer's in activities that distract or redirect their focus can be helpful. This approach can alleviate the spouse's concerns and provide some relief from exhaustion.
C. Ask the spouse what she knows and has considered about dementia care options.
While discussing dementia care options with the spouse is important, it might not directly address the spouse's current exhaustion and feelings of helplessness.
D. Educate the spouse about the availability of adult care as a respite.
This is a correct choice. Educating the spouse about adult care options for respite can provide much-needed breaks for the caregiver. Caring for someone with Alzheimer's can be emotionally and physically draining, so respite care can offer temporary relief.
E. Suggest that the spouse consults with the physician for anti-anxiety drugs.
Suggesting anti-anxiety drugs for the spouse is not the best first action. While addressing caregiver stress is important, suggesting medication should come after considering other supportive measures.
Full Explanation
The correct answers are choices B and D: "Offer ideas for ways to distract or redirect the client." and "Educate the spouse about the availability of adult care as a respite."
Choice A rationale:
Suggesting a long-term care facility should not be the first action. Early-stage Alzheimer's clients can often remain at home with proper support, and suggesting institutionalization might not be appropriate at this stage.
Choice B rationale:
This is a correct choice. Engaging the client with Alzheimer's in activities that distract or redirect their focus can be helpful. This approach can alleviate the spouse's concerns and provide some relief from exhaustion.
Choice C rationale:
While discussing dementia care options with the spouse is important, it might not directly address the spouse's current exhaustion and feelings of helplessness.
Choice D rationale:
This is a correct choice. Educating the spouse about adult care options for respite can provide much-needed breaks for the caregiver. Caring for someone with Alzheimer's can be emotionally and physically draining, so respite care can offer temporary relief.
Choice E rationale:
Suggesting anti-anxiety drugs for the spouse is not the best first action. While addressing caregiver stress is important, suggesting medication should come after considering other supportive measures.
A nurse is admitting a client who is about to undergo surgery for benign prostatic hypertrophy. The client states, "I don't know what I will do if they find that I have cancer." Which of the following should be the appropriate response by the nurse?
A. "I'm looking at your chart here, and I don't see any reason for you to worry about that."
Dismissing the client's concerns and saying there's no reason to worry is not empathetic. It invalidates the client's feelings and does not address their anxiety.
B. "I think that's something you need to discuss with your provider."
While discussing concerns with the provider is important, it's not the most therapeutic initial response. The nurse should engage with the client's feelings before suggesting actions.
C. "I'm hearing that you are concerned that it might turn out that you have cancer."
This is the correct choice. Reflecting the client's concerns back to them shows empathy and encourages them to express their feelings. This approach opens up communication and allows the nurse to provide support.
D. "Why do you think you might have cancer when your diagnosis is a benign condition?”
Asking the client why they think they might have cancer could come across as confrontational and dismissive. The focus should be on understanding their feelings rather than challenging their thoughts.
Full Explanation
The correct answer is choice C: "I'm hearing that you are concerned that it might turn out that you have cancer."
Choice A rationale:
Dismissing the client's concerns and saying there's no reason to worry is not empathetic. It invalidates the client's feelings and does not address their anxiety.
Choice B rationale:
While discussing concerns with the provider is important, it's not the most therapeutic initial response. The nurse should engage with the client's feelings before suggesting actions.
Choice C rationale:
This is the correct choice. Reflecting the client's concerns back to them shows empathy and encourages them to express their feelings. This approach opens up communication and allows the nurse to provide support.
Choice D rationale:
Asking the client why they think they might have cancer could come across as confrontational and dismissive. The focus should be on understanding their feelings rather than challenging their thoughts.
A nurse is teaching a newly licensed nurse about reporting suspected child abuse. Which of the following statements indicates that the newly licensed nurse has the correct information about child abuse?
A. "If the potential abuser commits to stopping the abuse, healthcare workers are not required to report it."
If the potential abuser commits to stopping the abuse, healthcare workers are not required to report it. Rationale: This statement is incorrect. Healthcare workers are mandated reporters, and their primary responsibility is to protect the safety and well-being of the child. Regardless of whether the potential abuser commits to stopping the abuse, suspicion of abuse requires reporting.
B. "Evidence must exist before reporting."
Evidence must exist before reporting. Rationale: This statement is incorrect. While concrete evidence can strengthen a case, it is not a prerequisite for reporting suspected child abuse. Reporting is based on reasonable suspicion, not proof. Healthcare workers should err on the side of caution and report any concerns.
C. "I don't want to defame someone if the report is false."
I don't want to defame someone if the report is false. Rationale: This statement is incorrect. Reporting suspected child abuse is not about defaming someone, but rather about ensuring the safety of the child. Reporting is a part of the legal and ethical obligations of healthcare workers to protect vulnerable individuals.
D. "If suspicion of abuse exists, then reporting is mandatory.”
If suspicion of abuse exists, then reporting is mandatory. Rationale: This statement is correct. Healthcare workers are mandated reporters and have a duty to report suspected child abuse to appropriate authorities. Reporting is necessary when there is reasonable suspicion, even if definitive evidence is not yet present.
Full Explanation
The correct answer is choice D: "If suspicion of abuse exists, then reporting is mandatory."
Choice A rationale:
If the potential abuser commits to stopping the abuse, healthcare workers are not required to report it. Rationale: This statement is incorrect. Healthcare workers are mandated reporters, and their primary responsibility is to protect the safety and well-being of the child. Regardless of whether the potential abuser commits to stopping the abuse, suspicion of abuse requires reporting.
Choice B rationale:
Evidence must exist before reporting. Rationale: This statement is incorrect. While concrete evidence can strengthen a case, it is not a prerequisite for reporting suspected child abuse. Reporting is based on reasonable suspicion, not proof. Healthcare workers should err on the side of caution and report any concerns.
Choice C rationale:
I don't want to defame someone if the report is false. Rationale: This statement is incorrect. Reporting suspected child abuse is not about defaming someone, but rather about ensuring the safety of the child. Reporting is a part of the legal and ethical obligations of healthcare workers to protect vulnerable individuals.
Choice D rationale:
If suspicion of abuse exists, then reporting is mandatory. Rationale: This statement is correct. Healthcare workers are mandated reporters and have a duty to report suspected child abuse to appropriate authorities. Reporting is necessary when there is reasonable suspicion, even if definitive evidence is not yet present.