The nurse is teaching a client about lorazepam. The nurse should instruct the client to expect which of the following side effects?

Hypertension

Tinnitus

Metallic taste

Dizziness

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Hypertension.

Hypertension, or high blood pressure, is not a common side effect of lorazepam. Lorazepam is a benzodiazepine, which typically causes sedation and relaxation of muscles, leading to a decrease in blood pressure rather than an increase. Therefore, hypertension is not an expected side effect of this medication.

Choice B Reason:

Tinnitus.

Tinnitus, or ringing in the ears, is also not commonly associated with lorazepam use. While tinnitus can be a side effect of various medications, it is not typically linked to benzodiazepines like lorazepam. Therefore, it is not an expected side effect for clients taking this medication.

Choice C Reason:

Metallic taste.

A metallic taste is not a common side effect of lorazepam. This side effect is more often associated with other medications, such as certain antibiotics or chemotherapy drugs. Lorazepam’s side effects are more related to its sedative properties.

Choice D Reason:

Dizziness.

Dizziness is a common side effect of lorazepam. As a central nervous system depressant, lorazepam can cause drowsiness, dizziness, and lightheadedness. Clients should be advised to avoid activities that require alertness, such as driving, until they know how the medication affects them.

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Correct Answer is A

Explanation

Choice A Reason:

Seclusion is used in psychiatric settings primarily to manage patients who are exhibiting aggressive or severely disturbed behavior. The reduced sensory input in a seclusion room helps the patient to regain control over their emotions and behavior by minimizing external stimuli that could exacerbate their condition. This controlled environment can be crucial in preventing harm to the patient and others, and it allows the patient to calm down in a safe space. The goal is to provide a therapeutic setting that aids in the patient’s recovery and stabilization.

Choice B Reason:

While communication is an essential part of psychiatric care, seclusion is not intended to encourage interaction with others. In fact, seclusion is used when a patient needs to be isolated to prevent harm to themselves or others. Encouraging communication is more appropriate in other therapeutic settings where the patient is stable and can engage safely with others. Therefore, this statement does not accurately explain the purpose of seclusion.

Choice C Reason:

Forcing clients to be responsible for themselves is not the primary goal of seclusion. Seclusion is a measure taken to ensure safety and to help the patient regain control over their behavior in a controlled environment. Responsibility and self-management are important aspects of psychiatric treatment, but they are typically addressed through other therapeutic interventions and not through seclusion. Thus, this statement is not an accurate explanation of the use of seclusion.

Choice D Reason:

Managing the unit with fewer staff is not a valid reason for using seclusion. The primary purpose of seclusion is to ensure the safety of the patient and others, not to reduce staffing needs. In fact, the use of seclusion requires careful monitoring and adherence to strict protocols, which can actually increase the need for staff attention. Therefore, this statement does not correctly explain the rationale behind the use of seclusion.

A. Documentation of the event will include interventions attempted prior to initiating restraints. B. The physician must be present at the time of the restraint episode. C. The client will be turned every 2 hours. D. The client will need to be monitored every one-half hour.

Correct Answer is ["A","C","D"]

Explanation

Choice A Reason:

The statement “Documentation of the event will include interventions attempted prior to initiating restraints” is correct. Proper documentation is crucial when restraints are used. This includes detailing the client’s behavior that necessitated the restraint, the interventions attempted before applying the restraint, the type of restraint used, and the time it was applied. This documentation ensures transparency and accountability, and it helps in evaluating the necessity and appropriateness of the restraint use.

Choice B Reason:

The statement “The physician must be present at the time of the restraint episode” is incorrect. While a physician’s order is required for the use of restraints, the physician does not need to be physically present at the time of the restraint episode. However, the physician must evaluate the client within a specified time frame after the restraint is applied, typically within one hour. This ensures that the restraint is medically justified and that the client’s condition is appropriately monitored.

Choice C Reason:

The statement “The client will be turned every 2 hours” is correct. Clients in restraints must be regularly repositioned to prevent complications such as pressure ulcers and to ensure their comfort. Turning the client every 2 hours is a standard practice to maintain skin integrity and promote circulation. This intervention is part of the comprehensive care plan for clients in restraints.

Choice D Reason:

The statement “The client will need to be monitored every one-half hour” is correct. Frequent monitoring of clients in restraints is essential to ensure their safety and well-being. This includes checking for signs of distress, ensuring that the restraints are not causing harm, and assessing the client’s vital signs5. Monitoring every 30 minutes helps in promptly addressing any issues that may arise and ensures that the restraints are used safely and effectively.

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The nurse is teaching a client about lorazepam. The nurse should instruct the client to expect which of the following side effects?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in orientation is rotating to a psychiatric unit where they observe a client in seclusion. Which of the following statements by the nurse’s preceptor best explains the use of seclusion on a unit?

Correct Answer is A

Explanation

When placing an agitated client in restraints, the nurse understands that which of the following must occur?

Correct Answer is ["A","C","D"]

Explanation

A client on an acute psychiatric inpatient unit approaches the nurse’s station every 10-15 minutes with various requests. The nurse intervenes by stating, “You may approach the nurse’s station only once an hour.” Which nursing intervention has been employed?

The nurse is teaching a client about lorazepam. The nurse should instruct the client to expect which of the following side effects?

A nurse is caring for a client who has schizophrenia and is experiencing command auditory hallucinations. Which of the following actions should the nurse take?

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Which action should the nurse take prior to educating clients about relaxation techniques?

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