A nurse is caring for a client who just received lorazepam 1 mg IM for anxiety. Which of the following actions should the nurse take?
Instruct the client to expect ringing in the ears.
Place the client in restraints for 1 hour.
Initiate fall precautions for the client.
Repeat the dose in 15 minutes if the client is still anxious.
The Correct Answer is C
Choice A reason: Ringing in the ears is not a common side effect of lorazepam. This medication is more likely to cause drowsiness or dizziness, which could increase the risk of falls.
Choice B reason: Restraints should only be used as a last resort when all other options have been exhausted and the client is a danger to themselves or others. Lorazepam is used to reduce anxiety, not to sedate to the point where restraints would be necessary.
Choice C reason: Initiating fall precautions is a prudent nursing action after administering lorazepam, especially if given intramuscularly, as the client may experience drowsiness or dizziness, increasing the risk of falls.
Choice D reason: Repeating the dose in 15 minutes is not recommended. The effects of lorazepam should be monitored, and additional doses should be administered based on the client's response and as prescribed by the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This response is appropriate because it respects the client's autonomy and comfort level. It is essential to acknowledge the client's feelings and preferences, especially when dealing with mental health issues like panic disorder. Massage therapy, while beneficial for some, may not be suitable for everyone, particularly if the idea of being touched exacerbates the client's anxiety. By offering to communicate the client's concerns to the provider, the nurse acts as an advocate for the client's well-being and ensures that the treatment plan is tailored to the client's specific needs and comfort.
Choice B reason: While this option might seem like a compromise, it does not address the client's fundamental discomfort with being touched. Wearing gloves may not alleviate the distress associated with physical contact for someone with panic disorder. It is crucial to consider the client's psychological state and the potential for gloves to serve as a reminder of the unwanted touch, possibly leading to increased anxiety rather than relief.
Choice C reason: Asking the client to explain their discomfort could be seen as dismissive of the client's stated boundaries and may put them in an uncomfortable position to justify their feelings. It is important for healthcare professionals to create a safe and supportive environment where clients do not feel pressured to defend their preferences or feelings, especially when they are already experiencing distress.
Choice D reason: This choice minimizes the client's concerns and could be perceived as invalidating their feelings. Telling a client not to worry about their anxiety, particularly in the context of a panic disorder, overlooks the complexity of the condition. Anxiety disorders can significantly impact a person's life, and reassurances like this may not be helpful and could potentially worsen the client's anxiety.
Correct Answer is B
Explanation
Choice A reason: Providing detailed explanations to a client with moderate anxiety might overwhelm them and exacerbate their anxiety. While information is important, too much detail can be counterproductive in this context.
Choice B reason: Using short, simple sentences can help ensure that the client with moderate anxiety comprehends the information without becoming overwhelmed. This approach is conducive to learning and retention, especially when the client is anxious.
Choice C reason: Avoiding asking the client questions may seem like a way to reduce stress, but it can actually hinder engagement and understanding. Questions can help clarify the client's comprehension and provide them with a sense of involvement in their care.
Choice D reason: Showing a 30-minute teaching video might be informative, but it could be too lengthy for a client with moderate anxiety. The client may benefit more from interactive and personalized teaching methods that allow for breaks and questions as needed.
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