A nurse is caring for an older adult client who has a prescription for lorazepam 0.5 mg. Which of the following findings should the nurse report to the provider immediately?

Disorientation

Anorexia

Increased anxiety

Blurred vision

Answer and Explanation

The Correct Answer is A

A. Disorientation in an older adult after taking lorazepam could indicate an adverse reaction or an excessive sedative effect. It's crucial to report this immediately as it may signify an overdose or an adverse reaction to the medication. Older adults are more sensitive to the sedative effects of benzodiazepines, and disorientation can indicate potential serious side effects.

B. Anorexia (loss of appetite) is a possible side effect of lorazepam but is not typically considered an urgent or immediate concern unless it leads to severe dehydration or other complications.

C. Increased anxiety could potentially occur due to paradoxical reactions to benzodiazepines; however, it's not typically considered an urgent or immediate concern unless it's severe or distressing to the client.

D. Blurred vision is a common side effect of lorazepam and other benzodiazepines. While it should be monitored and reported, it might not be considered an urgent concern unless it's significantly affecting the client's ability to function or is accompanied by other severe symptoms.

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Correct Answer is D

Explanation

A. Keeping the lights on when the client is sleeping is not a standard intervention for seizure precautions. In fact, it's generally recommended to create a quiet and low-stimulus environment for clients with seizure disorders.

B. Restraining the client as soon as seizure activity begins is not recommended. Restraints can lead to injuries and complications during a seizure. It is essential to allow the client to move and prevent injury by removing harmful objects from the vicinity.

C. Having a padded tongue depressor available at the bedside is not a standard intervention for seizure precautions. In the event of a seizure, the priority is to keep the client safe, protect their head, and ensure a clear airway. Placing objects in the mouth is not recommended and can lead to injury.

D. Keeping the client's bed in the lowest position is a safety measure to prevent injuries during a seizure. It reduces the risk of falling from a significant height in case of a seizure episode.

A. Provide support by holding the client's arm. B. Maintain a narrow base of support. C. Lower the client to the floor. D. Lean the client toward the wall.

Correct Answer is C

Explanation

A. Provide support by holding the client's arm:

While providing support is essential, holding the client's arm may not prevent a fall. It's better to focus on a controlled descent to the floor.

B. Maintain a narrow base of support:

Maintaining a narrow base of support is not advisable when a client is falling. A wider base of support provides more stability.

C. Lower the client to the floor:

This is the correct action. When a client begins to fall, the nurse should lower them to the floor in a controlled manner to minimize the risk of injury.

D. Lean the client toward the wall:

Leaning the client toward the wall may not provide sufficient support during a fall. The goal is to lower the client to the floor in a way that minimizes the risk of injury.

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A nurse is caring for an older adult client who has a prescription for lorazepam 0.5 mg. Which of the following findings should the nurse report to the provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a medical unit is caring for a client who requires seizure precautions. Which of the following interventions should the nurse contribute to the client's plan of care?

Correct Answer is D

Explanation

A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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