A nurse is planning care for a client who is in the manic phase of bipolar disorder.

Which of the following interventions should the nurse include in the client's plan of care?.

Choice A rationale:

Asking "Why do you believe you are hearing voices?" is not a suitable response because it challenges the client's reality and can make them feel defensive or invalidated. It's important to validate the client's experience and avoid questioning the reality of their hallucinations.

It can also imply that the client is somehow responsible for their hallucinations, which can be stigmatizing and distressing.

It's more helpful to focus on the content of the hallucinations and how they are affecting the client, rather than on the cause of the hallucinations.

Choice B rationale:

Asking "What are the voices instructing you to do?" is a suitable response because it allows the nurse to assess the content of the hallucinations and the potential for harm.

This information can be used to develop a safety plan and to help the client manage their symptoms.

It also demonstrates to the client that the nurse is taking their concerns seriously and is interested in understanding their experience.

Choice C rationale:

Telling the client "You need to comprehend that there are no voices" is not a suitable response because it is dismissive of the client's experience and can make them feel like they are not being heard or understood.

It's important to remember that hallucinations are very real to the person experiencing them, and telling them that they are not real is not helpful.

It can also damage the therapeutic relationship between the nurse and the client.

Choice D rationale:

Asking "Are the voices familiar to you?" is not a suitable initial response because it is not directly relevant to the client's safety or to the assessment of their symptoms.

While it may be helpful to gather information about the nature of the voices at some point, the priority is to assess the potential for harm and to develop a safety plan.

Choice A rationale:

Disorientation is a significant neurological finding that can signal a serious adverse reaction to lorazepam, particularly in older adults. It's crucial to report it immediately to the provider for prompt assessment and intervention.

Lorazepam, a benzodiazepine, can cause central nervous system (CNS) depression, which can manifest as disorientation, confusion, memory impairment, and even delirium.

Older adults are more vulnerable to CNS depressant effects due to age-related physiological changes, such as decreased metabolism and clearance of medications, as well as increased brain sensitivity.

Early identification and management of disorientation can prevent potential complications, such as falls, injuries, and worsening cognitive decline.

Choice B rationale:

Increased anxiety can be a paradoxical reaction to lorazepam, but it's not as immediately concerning as disorientation in terms of potential for serious harm.

The nurse should still monitor anxiety levels and report any significant changes to the provider, as dosage adjustments or alternative medications may be necessary.

Choice C rationale:

Blurred vision is a common side effect of lorazepam, but it's typically mild and transient.

It's important to assess the severity and duration of blurred vision and report it to the provider if it persists or interferes with daily activities.

Choice D rationale:

Anorexia, or loss of appetite, can be a side effect of lorazepam, but it's not as urgent as disorientation.

The nurse should monitor the patient's nutritional intake and weight, and report any significant changes to the provider.