A nurse is caring for a client who has Alzheimer’s disease. Which of the following findings should the nurse expect?

Choice A reason: Narcissistic personality disorder involves grandiosity and interpersonal issues, not sensory impairments. There’s no direct link to vision, hearing, or motor deficits unless secondary conditions exist. Assessment priority would focus on behavior, not sensory risks, making this client less likely for this concern at shift start.

Choice B reason: Mild anxiety disorder causes worry or restlessness, but sensory impairments aren’t typical features. Physical symptoms like palpitations don’t equate to sensory loss. Other clients with neurological risks take precedence, so this client’s mild condition doesn’t warrant immediate sensory assessment.

Choice C reason: Severe OCD involves intrusive thoughts and rituals, potentially distracting from sensory input, but not impairing it directly. Sensory issues aren’t a hallmark, and assessment would target compulsions. This client’s risks are behavioral, not sensory, lowering their priority here.

Choice D reason: Conversion disorder presents with neurological symptoms like blindness or paralysis without organic cause, mimicking sensory impairments. Assessing this client first ensures safety, as these deficits could be active, posing immediate risks like falls. This aligns with the focus on sensory concerns, making it the priority.

Choice A reason: Ringing in the ears (tinnitus) isn’t a common lorazepam side effect; sedation, confusion, or dizziness are. Instructing this misinforms the client, potentially causing undue worry. Post-IM administration focuses on monitoring actual effects, not unrelated symptoms. This action lacks relevance to lorazepam’s profile, so it’s incorrect.

Choice B reason: Restraints for 1 hour post-lorazepam assume behavioral control needs without evidence of aggression. This violates least restrictive care, risking harm or agitation in an anxious client. Lorazepam calms, not escalates, behavior, making restraints unnecessary and unethical unless danger emerges.

Choice C reason: Repeating lorazepam in 15 minutes risks oversedation, as 1 mg IM peaks in 60-90 minutes, needing time to assess efficacy. Protocol requires monitoring, not immediate redosing, absent severe symptoms. This premature action endangers respiratory safety, so it’s not appropriate.

Choice D reason: Lorazepam’s sedative effects (drowsiness, dizziness) increase fall risk post-IM injection, especially in anxiety where mobility may persist. Initiating precautions like bed alarms or assistance ensures safety, a priority after benzodiazepine use. This action aligns with standard care, making it the correct choice.