A patient whose behavior has continued to escalate despite ...

[Diane]

A patient whose behavior has continued to escalate despite nursing interventions begins to kick and strike out at the nurse. What is the priority nursing intervention?
 
  a. Offer an oral PRN medication.
  b. Have staff stand by at a distance.
  c. Physically control the patient's behavior.
  d. Allow the behavior until the patient de-escalates.

Question 2

A patient diagnosed with agoraphobia took alprazolam (Xanax) 0
 
  5 mg three times daily for 3 months and then discontinued it. The next day the patient called the nurse reporting insomnia, shakiness, and sweating. The nurse's assessment questions should focus on whether the patient:
  a. may have also been drinking alcohol or taking antihistamines.
  b. has built up tolerance to alprazolam and needs an increased dose.
  c. is having withdrawal symptoms from abrupt discontinuation of the drug.
  d. has progressed to panic attacks and needs a non-benzodiazepine medication.

[fromAlphatoOmega22]

Answer to Question 1

C
When a patient loses control, staff must take physical control to prevent injury to the patient or others. A determination must then be made as what measures are necessary (intramuscular medication, involuntary seclusion, or restraint), keeping in mind the importance of using the least restrictive alternatives that will achieve the goal of safety.

Answer to Question 2

C
The patient's symptoms suggest benzodiazepine withdrawal. The nurse knows that patients often attempt to manage their own care by discontinuing medication when they begin to feel better. Benzodiazepines should be slowly withdrawn if withdrawal symptoms are to be avoided. Drinking alcohol would result in different symptoms. Development of tolerance and panic attack symptoms would be different from those mentioned.