A mental health nurse is caring for a client who has schizophrenia and generalized anxiety disorder (GAD). The client has a prescription for lorazepam 2 mg PO every 6 hr PRN anxiety.
For which of the following client statements should the nurse consider administering lorazepam?
The client tells the nurse that he is too tired to attend the group meeting.
The client states, "I see purple bugs crawling on the wall."
The client tells the nurse he is a government agent.
The client states, "My heart is pounding out of my chest.".
The Correct Answer is D
Choice A rationale: Feeling too tired to attend a group meeting does not necessarily indicate anxiety. It could be due to various reasons such as lack of sleep, side effects of medication, or lack of motivation, which are not indications for administering lorazepam.
Choice B rationale: Seeing “purple bugs crawling on the wall” is a hallucination, which is a symptom of schizophrenia, not anxiety. Lorazepam is not typically used as the first-line treatment for hallucinations.
Choice C rationale: Believing that he is a government agent is a delusion, which is a symptom of schizophrenia. Lorazepam is not typically used as the first-line treatment for delusions.
Choice D rationale: “My heart is pounding out of my chest” is a common symptom of anxiety. It indicates that the client might be experiencing physiological symptoms of anxiety such as increased heart rate and palpitations. In this case, administering lorazepam, which is an anxiolytic medication, would be appropriate.
In conclusion, the nurse should consider administering lorazepam when the client states, “My heart is pounding out of my chest.”
Lorazepam is a medication belonging to the benzodiazepine class, commonly used to treat anxiety and insomnia. It works by slowing down the activity in the brain and nervous system, producing a calming effect.
Generalized Anxiety Disorder (GAD) is a chronic mental health condition characterized by excessive worry and anxiety that persists for at least 6 months, interfering with daily life.
Important Considerations:
Lorazepam is a controlled substance due to its potential for abuse and dependence.
It should only be administered under the supervision of a qualified healthcare professional, who can assess the individual's needs and potential risks.
Self-treating with lorazepam is dangerous and can lead to serious consequences.
If you have concerns about anxiety or are considering using lorazepam, please consult a licensed physician or mental health professional for proper diagnosis and treatment guidance.
Remember,
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
The nurse should administer 2 tablets per dose.
Rationale:
Step 1: Determine the desired dose of diphenhydramine. The desired dose is 50 mg.
Step 2: Determine the available tablet strength. The available tablet strength is 25 mg.
Step 3: Divide the desired dose by the tablet strength to determine the number of tablets needed. 50 mg / 25 mg/tablet = 2 tablets
Therefore, the nurse should administer 2 tablets of diphenhydramine 25 mg per dose to achieve the desired dose of 50 mg.
Correct Answer is B
Explanation
The correct answer is choice b. Moderate.
Choice A rationale: Severe anxiety is characterized by a significant reduction in the ability to perceive and process information. The individual may experience intense physical symptoms such as dizziness, hyperventilation, and a sense of impending doom. The client’s ability to focus is greatly diminished, and they may have difficulty functioning.
Choice B rationale: Moderate anxiety involves a heightened sense of awareness and a narrowing of the perceptual field. The individual may experience physical symptoms such as increased heart rate, sweating, and muscle tension. They can still focus and problem-solve but may need assistance. The client’s symptoms of chest pain, headache, and shortness of breath, along with their emotional distress, align with moderate anxiety.
Choice C rationale: Mild anxiety is associated with a slight increase in alertness and perception. The individual may feel restless and have minor physical symptoms like slight muscle tension. They can still function effectively and use coping mechanisms to manage their anxiety.
Choice D rationale: Panic level anxiety is the most severe form and involves a complete disruption of the ability to function. The individual may experience extreme physical symptoms such as chest pain, palpitations, and a sense of losing control. They may be unable to communicate effectively or respond to their environment.
Each level of anxiety presents differently, and understanding these differences helps in providing appropriate care and interventions.
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