A nurse is preparing to administer lorazepam to a patient with acute anxiety. Which intervention is most important for the nurse to consider?

Correct Answer: A

Rationale: In the context of administering lorazepam to a patient with acute anxiety, the most important intervention for the nurse to consider is monitoring for signs of excessive sedation (Option A). Lorazepam is a benzodiazepine that can cause sedation as a common side effect. Monitoring for excessive sedation is crucial as it can lead to respiratory depression, especially in patients with compromised respiratory function. Option B, ensuring the patient is hydrated before administration, is not directly related to the safe administration of lorazepam. While hydration is important for overall health, it is not a specific consideration when administering this medication. Option C, administering the medication only after meals, is not a key consideration for lorazepam administration. In fact, it is often given on an empty stomach to facilitate faster absorption. Option D, monitoring the patient for signs of depression, is not directly related to the immediate effects of lorazepam administration. While monitoring for mental health changes is important in general nursing care, it is not the most critical consideration when administering lorazepam for acute anxiety. In an educational context, nurses need to understand the pharmacological properties of medications they administer, common side effects, and appropriate monitoring strategies to ensure patient safety. Understanding the specific considerations for each medication is crucial in providing effective and safe care to patients with behavioral health needs.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Tuna sandwich. The rationale behind recommending a tuna sandwich lies in the nutritional benefits it offers to individuals with Alzheimer's disease. Tuna is rich in omega-3 fatty acids, specifically DHA, which has been linked to brain health and potentially slowing the progression of cognitive decline in Alzheimer's patients. Omega-3 fatty acids are known to have neuroprotective properties and can help support brain function. Now, let's discuss why the other options are not the best choice for a client with Alzheimer's disease. Option B) Hamburgers are typically high in saturated fats and cholesterol, which are not ideal for individuals with Alzheimer's as they can contribute to cardiovascular issues that may exacerbate cognitive decline. Option C) Turkey sandwich is a healthier choice compared to hamburgers, but it may not provide the same benefits as tuna in terms of omega-3 fatty acids crucial for brain health. Option D) Cheese pizza is high in saturated fats, sodium, and low in the essential nutrients needed for brain health, making it a less optimal choice for individuals with Alzheimer's disease. From an educational standpoint, it is essential for nurses to understand the role of nutrition in managing chronic conditions like Alzheimer's disease. By recommending foods rich in nutrients like omega-3 fatty acids, nurses can contribute to the overall well-being of their patients and potentially slow down the progression of the disease. This knowledge empowers nurses to provide holistic care that addresses not just the symptoms but also the underlying factors contributing to the condition.

Correct Answer: D

Rationale: The correct answer is D) Secondary trauma. In this scenario, the nurse working on a Covid-19 unit is likely experiencing secondary trauma, which occurs when an individual is indirectly exposed to traumatic events through their work with traumatized individuals. The nurse on the mental health hotline is hearing about the struggles of the nurse from the Covid-19 unit, leading to emotional distress and a questioning of their nursing career. Option A) Acute trauma refers to a single traumatic event, which does not fit the ongoing stress and impact of working on a Covid-19 unit. Option B) Chronic trauma typically involves repeated exposure to traumatic events over time but does not capture the indirect nature of the trauma experienced by the nurse on the hotline. Option C) Complex trauma involves exposure to multiple traumatic events, often in childhood, and does not align with the current situation described in the question. Understanding secondary trauma is crucial for nurses working in behavioral health settings as it can impact their own mental health and job satisfaction. Recognizing the signs and symptoms of secondary trauma allows nurses to seek support, practice self-care, and continue providing effective care to their patients.

Correct Answer: B

Rationale: In this scenario, the most therapeutic response by the nurse is option B: "Let's talk about what specifically makes you feel overwhelmed." This response demonstrates active listening, empathy, and a patient-centered approach, which are crucial in caring for individuals with generalized anxiety disorder. Option A is not the best choice because it dismisses the patient's feelings and minimizes their experience by suggesting they focus on the bigger picture, which may invalidate their emotions. This response lacks empathy and fails to address the patient's immediate concerns. Option C is not recommended as it oversimplifies the experience of someone with generalized anxiety disorder by suggesting they simply control their thoughts and stop worrying. This response ignores the complexity of the disorder and may make the patient feel misunderstood or blamed for their condition. Option D is not the most appropriate response as it encourages avoidance behavior, which can reinforce anxiety in the long run. Encouraging avoidance can hinder the patient's ability to confront and cope with their anxiety triggers, ultimately impeding their progress in managing their condition effectively. In an educational context, it is vital for nurses to develop strong communication skills, empathy, and a patient-centered approach when caring for individuals with behavioral health disorders. Active listening, validating emotions, and offering support are key components of providing effective care to patients with generalized anxiety disorder. By choosing the most therapeutic responses, nurses can foster trust, build rapport, and promote a therapeutic relationship with their patients, ultimately enhancing patient outcomes and well-being.

Correct Answer: B

Rationale: In caring for a patient with bipolar disorder in the manic phase, providing a calm environment to reduce external stimulation (option B) should be implemented first. This intervention is crucial as it helps decrease the patient's agitation and can prevent escalating behavior. Encouraging social activities (option A) may exacerbate the symptoms due to increased stimulation. Offering medication (option C) is important but may not have an immediate effect in managing acute manic symptoms. Setting firm limits (option D) may agitate the patient further and should be used cautiously. Educationally, understanding the importance of environment in managing acute behavioral health crises is key. Nurses need to prioritize interventions that promote a safe and calming atmosphere to support patients in regaining control during manic episodes. This rationale highlights the significance of tailored care strategies in psychiatric nursing practice.