A patient is given lorazepam, a benzodiazepine, to decrease symptoms of anxiety and restlessness on the evening prior to planned surgery. The nurse knows that the patient is experiencing a paradoxical drug reaction when which of the following is assessed?

A macular rash on the chest and back.

Increased appetite.

Drowsiness and mild sedation.

Increased agitation and insomnia.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

A macular rash on the chest and back is not indicative of a paradoxical drug reaction to lorazepam, a benzodiazepine. Paradoxical reactions involve unexpected and opposite responses to a medication, such as increased agitation and excitement instead of the intended calming effect. A rash is not consistent with this type of reaction.

Choice B rationale:

Increased appetite is not associated with a paradoxical drug reaction to lorazepam. Paradoxical reactions involve behavioral and physiological responses that are contrary to the expected effects of the medication. Increased appetite does not fit this pattern.

Choice C rationale:

Drowsiness and mild sedation are the intended effects of lorazepam, a benzodiazepine. Paradoxical reactions are characterized by unexpected and opposite responses. Drowsiness and mild sedation align with the expected pharmacological actions of benzodiazepines, making this choice incorrect for a paradoxical reaction.

Choice D rationale:

Increased agitation and insomnia are indicative of a paradoxical drug reaction to lorazepam. Benzodiazepines like lorazepam are central nervous system depressants and are commonly used to treat anxiety and promote sedation. However, in some cases, paradoxical reactions can occur, leading to increased agitation, excitement, and even insomnia. These reactions are thought to be more common in children and older adults. This choice is correct because it aligns with the characteristics of a paradoxical reaction.

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Correct Answer is B

Explanation

Choice A rationale:

Stage I Pressure ulcer - This choice is not correct because a Stage I pressure ulcer is characterized by intact skin with non-blanchable redness over a bony prominence. There is no partial-thickness skin loss at this stage.

Choice B rationale:

Stage II Pressure ulcer - This is the correct choice. A Stage II pressure ulcer involves partial-thickness skin loss that presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also manifest as an intact or open/ruptured serum-filled blister.

Choice C rationale:

Stage IV Pressure ulcer - This choice is not correct because a Stage IV pressure ulcer involves full-thickness tissue loss with exposed bone, tendon, or muscle. There is no mention of such extensive tissue loss in the given scenario.

Choice D rationale:

Stage II Pressure ulcer - This choice is a duplicate of Choice B and is not correct for the reasons stated above.

A. "My child must be free from nits before returning to school.” B. "Toys that can't be dry cleaned or washed must be thrown out.” C. "I will treat all the family members to be on the safe side.” D. "All recently used clothing, bedding, and towels must be washed in hot water.”

Correct Answer is D

Explanation

Choice A rationale:

Requiring the child to be free from nits before returning to school might not be an accurate understanding of the situation. Nits are the eggs of head lice and may remain attached to the hair even after effective treatment. The presence of live lice is a more crucial factor to consider.

Choice B rationale:

Throwing out toys that can't be dry cleaned or washed is an unnecessary and extreme measure. Head lice do not survive long away from the human scalp, so the risk of transmission through inanimate objects like toys is minimal. Thoroughly cleaning and vacuuming the environment is more effective.

Choice C rationale:

Treating all family members is indeed a prudent approach. Head lice can spread easily within households, especially among close contacts. Treating everyone helps prevent re-infestation and disrupts the lice life cycle.

Choice D rationale:

Washing recently used clothing, bedding, and towels in hot water is a correct understanding of how to manage head lice. The high temperature kills lice and their eggs. It is an essential step in preventing the spread of lice and re-infestation.

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A patient is given lorazepam, a benzodiazepine, to decrease symptoms of anxiety and restlessness on the evening prior to planned surgery. The nurse knows that the patient is experiencing a paradoxical drug reaction when which of the following is assessed?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting an elderly client into a unit. During the initial assessment, the nurse notes an erythematous wound with partial-thickness skin loss. The wound does not contain slough and is located on the patient's right heel. How will the nurse stage this pressure ulcer?

Correct Answer is B

Explanation

A school nurse identifies that a child has pediculosis capitis (head lice) and educates the child's parents about the condition. Which of the following statements by the parents indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is educating a newly licensed nurse about ethical principles. Which of the following situations is an example of beneficence?

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take?

Which nurse kept records on sanitation techniques and the effects on health?

A nurse is examining the chest of a post-operative client. Upon palpation, the nurse notes a crackling sensation. Which of the following conditions would the nurse report to the provider?

A nurse is caring for a patient on a Medical-Surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?

A nurse is reviewing unintentional and intentional torts. Which of the following clinical situations would the nurse identify as an example of assault?