A nurse is caring for a client who is scheduled for surgical repair of a femur fracture and has a prescription for lorazepam preoperatively. Which of the following statements made by the client should indicate to the nurse that the medication has been effective?
"My mouth is very dry."
"My leg feels numb."
"I feel very sleepy."
"I am not hungry any longer."
The Correct Answer is C
A. "My mouth is very dry."
Dry mouth is a common side effect of lorazepam, but it does not directly indicate the effectiveness of the medication in reducing preoperative anxiety.
B. "My leg feels numb."
Numbness in the leg is not a typical effect of lorazepam and does not indicate the effectiveness of the medication in reducing preoperative anxiety.
C. "I feel very sleepy."
Feeling sleepy or drowsy is a common side effect of lorazepam, and it indicates that the medication has effectively reduced the client's preoperative anxiety.
D. "I am not hungry any longer."
Decreased appetite can be a side effect of lorazepam, but it is not a direct indicator of the medication's effectiveness in reducing preoperative anxiety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
(A) Kernig’s sign: Kernig’s sign is a clinical sign in which severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees. It is commonly associated with meningitis, not hypocalcemia.
(B) Brudzinski’s sign: Brudzinski’s sign is a symptom of meningitis. It is not associated with hypocalcemia.
(C) Chvostek’s sign: This is the most appropriate answer. Chvostek’s sign is a clinical sign of existing nerve hyperexcitability (tetany) seen in hypocalcemia. It refers to an abnormal reaction to the stimulation of the facial nerve.
(D) Cullen’s sign: Cullen’s sign is a medical term referring to superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus. It is not associated with hypocalcemia.
Correct Answer is C
Explanation
(A) Blood pressure 160/94 mm Hg:
Metoprolol is a beta-blocker commonly used to treat hypertension. A blood pressure reading of 160/94 mm Hg indicates hypertension, which is an indication for administering metoprolol, not withholding it.
(B) Oxygen saturation 95%:
An oxygen saturation of 95% is within the normal range and does not provide a reason to withhold metoprolol. Oxygen saturation levels are not directly impacted by this medication in a way that would warrant withholding it.
(C) Heart rate 50/min:
A heart rate of 50/min is bradycardia (a slow heart rate). Metoprolol can further lower the heart rate, so it should be withheld if the client is already experiencing bradycardia. The nurse should notify the healthcare provider for further instructions.
(D) Respiratory rate 18/min:
A respiratory rate of 18/min is within the normal range (12-20 breaths per minute) and does not provide a reason to withhold metoprolol. Respiratory rate is not typically a contraindication for this medication unless there are specific respiratory conditions or other related symptoms present.
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