The nurse is assessing a client presenting with diazepam intoxication.
What signs and symptoms are consistent with benzodiazepine intoxication? Select all that apply.

Ineffective protection related to chemotherapy side effects. This nursing diagnosis takes priority for a client who is receiving chemotherapy

treatment for cancer because chemotherapy can cause immunosuppression and increase the risk of infection, bleeding, and other complications.

According to the NANDA-I taxonomy, ineffective protection is defined as “decreased ability of an individual to guard the self from internal or external threats such as illness or injury” (NANDA International, 2018).

Choice A is wrong because situational low self-esteem related to job loss due to chemotherapy side effects is not a priority diagnosis for a client who is receiving chemotherapy treatment for cancer. Although chemotherapy can affect the client’s self-image and emotional well-being, it is not a life-threatening condition and can be addressed after ensuring the client’s safety and physiological needs.

Choice C is wrong because anticipatory grieving related to a cancer diagnosis is not a priority diagnosis for a client who is receiving chemotherapy treatment for cancer. Although cancer can cause emotional distress and grief for the client and their family, it is not an immediate threat to the client’s health and can be managed with psychological support and counseling.

Choice D is wrong because fatigue related to cancer treatments is not a priority diagnosis for a client who is receiving chemotherapy treatment for cancer. Although chemotherapy can cause fatigue and weakness, it is not a critical condition and can be alleviated with rest, nutrition, and energy conservation strategies.

The nurse should obtain a sputum culture specimen before administering any antibiotics to the client with bacterial pneumonia.

This is because the sputum culture can help identify the causative organism and the appropriate antibiotic therapy.

Administering antibiotics before obtaining the sputum culture can alter the results and lead to ineffective treatment.

Choice B is wrong because azithromycin is an antibiotic that should be given after obtaining the sputum culture.

Choice C is wrong because coughing and deep breathing are important interventions to promote airway clearance and gas exchange, but they are not the priority actions for this client.

Choice D is wrong because offering clear liquids can help prevent dehydration and thin secretions, but they are not the most urgent action for this client.

Normal ranges for blood urea nitrogen (BUN) are 7 to 20 mg/dL and for creatinine are 0.6 to

1.2 mg/dL.

Elevated levels of these substances can indicate renal impairment, which can be a complication of bacterial pneumonia.

The nurse should monitor these levels and report any abnormalities to the health care provider.