A client with anxiety and insomnia has been taking alprazolam (Xanax) for five days. What is the priority for the nurse to assess in this client?
1. Stopping the use of birth control pills
2. Thoughts of suicide
3. Taking the medication with grapefruit juice
4. Drowsiness after taking the medication
Correct Answer: 2
Rationale 1: Xanax is a category D drug, and should not be taken during pregnancy. However, the client should not stop taking birth control pills because of the risk of pregnancy.
Rationale 2: Examples of such behaviors that should be reported to the health care provider immediately include aggressiveness, hallucinations, suicidal thinking, and unusual extroversion or depersonalization. This could indicate a serious underlying psychiatric or medical condition that requires further assessment.
Rationale 3: Grapefruit or grapefruit juice taken while on Xanax might inhibit the metabolism of Xanax. The client should have been instructed to avoid grapefruit and grapefruit juice before starting the medication.
Rationale 4: Drowsiness is a common side effect of benzodiazepines that would not suddenly occur after taking the medication for 5 days.
Global Rationale: Examples of such behaviors that should be reported to the health care provider immediately include aggressiveness, hallucinations, suicidal thinking, and unusual extroversion or depersonalization. This could indicate a serious underlying psychiatric or medical condition that requires further assessment. Xanax is a category D drug, and should not be taken during pregnancy. However, the client should not stop taking birth control pills because of the risk of pregnancy. Grapefruit or grapefruit juice taken while on Xanax might inhibit the metabolism of Xanax. The client should have been instructed to avoid grapefruit and grapefruit juice before starting the medication. Drowsiness is a common side effect of benzodiazepines that would not suddenly occur after taking the medication for 5 days.
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