Correct Answer: C

Rationale: Elevated heart rate is not a typical sign of opioid toxicity. Opioids usually have a depressant effect on the cardiovascular system, leading to bradycardia. Hypertension is not a typical effect of opioid toxicity. Opioids often cause hypotension due to vasodilation. Pupillary constriction (miosis). Acute fentanyl toxicity is associated with opioid overdose, and opioids typically cause miosis (constriction of the pupils). Other common symptoms of opioid toxicity include respiratory depression, sedation, and potentially unconsciousness. Tachypnea is not a typical sign of opioid toxicity. Opioids tend to depress the respiratory system, leading to respiratory depression and potentially hypoventilation.

Correct Answer: C

Rationale: A single dose of diazepam is unlikely to cause side effects' is not accurate. Diazepam, like any medication, can have side effects even with a single dose. Common side effects include drowsiness, dizziness, and muscle weakness. 'Grapefruit juice inactivates this medication' is not specifically true for diazepam. However, grapefruit juice can interact with certain medications by inhibiting their metabolism in the liver, leading to increased levels of the drug in the bloodstream. It's essential to check for specific drug interactions, but this statement is not a key consideration for diazepam. 'Diazepam can cause drowsiness' is an important piece of information to include because diazepam is a benzodiazepine medication that can have sedative effects. Alerting the client to the potential for drowsiness is crucial to prevent any safety issues, such as falls or accidents. 'Avoid foods that contain tyramine' is not relevant to diazepam. Tyramine is associated with certain foods and can be a concern with medications called monoamine oxidase inhibitors (MAOIs). Diazepam is not an MAOI, so this advice does not apply to its use.

Correct Answer: D

Rationale: What happened to you in the past to make you so desperate?' may be seen as judgmental and may not be as helpful in the immediate crisis. It assumes a specific cause for the desperation and might not address the current feelings or circumstances that are contributing to the suicidal thoughts. 'What will you accomplish by taking your life?' This question may be perceived as confrontational or dismissive of the client's feelings. It might not provide a clear understanding of the immediate risk or plan. 'Why do you feel depressed enough to end your life?' is a direct question that may put pressure on the client and might not be as effective in exploring their thoughts and feelings. It assumes a direct link between depression and suicidal thoughts without allowing for a more nuanced exploration. 'How will you carry out your plan?' This question is crucial because it helps assess the seriousness of the client's intent and the immediacy of the risk. Understanding the specifics of the plan can help the nurse evaluate the level of danger and take appropriate actions to ensure the client's safety.

Correct Answer: A,B,D

Rationale: A. Sodium level: Correct. Sodium imbalances can have serious consequences, including neurological symptoms. Hyponatremia is a common electrolyte imbalance seen in anorexia nervosa. B. Blood pressure: Correct. Abnormal blood pressure, especially low blood pressure, can indicate cardiovascular compromise, which is a concern in severe cases of anorexia nervosa. C. Respiratory rate: Not selected. While monitoring respiratory rate is important, the client's pallor and capillary refill suggest potential issues with peripheral perfusion, making capillary refill more urgent. D. Capillary refill: Correct. Prolonged capillary refill time is a measure of peripheral perfusion and may indicate poor tissue perfusion, requiring immediate attention. E. Glucose level: Not selected. While monitoring glucose levels is important, hypoglycemia might not be an immediate concern in this scenario. The client's neurological symptoms may be more related to electrolyte imbalances. F. Phosphate level: Not selected. Monitoring phosphate levels is important, but severe abnormalities may not require immediate follow-up unless other critical issues are addressed first. G. Magnesium level: Not selected. Magnesium imbalances are significant but may not require immediate follow-up unless severe abnormalities are noted.

Correct Answer: C

Rationale: Foods that are high in dietary tyramine are more relevant to certain antidepressant medications, particularly monoamine oxidase inhibitors (MAOIs), and are not a specific concern with alprazolam. Increasing the dose of the medication without consulting the healthcare provider is not appropriate. Adjustments to the dosage should be done under the guidance of the healthcare provider. 'Avoid driving or operating heavy machinery until you know how alprazolam affects you.' This is an important safety consideration when using benzodiazepines such as alprazolam. Benzodiazepines can cause drowsiness and impair coordination, so clients should be advised to avoid activities that require mental alertness, such as driving or operating machinery, until they are aware of how the medication affects them. Manifestations of anxiety should improve with the use of alprazolam, and relief of symptoms can occur relatively quickly. However, it is essential to inform the client that long-term use of benzodiazepines may lead to tolerance and dependence. They should not abruptly stop the medication without consulting their healthcare provider.