A nurse is caring for a client who just received lorazepam 1 mg IM for anxiety. Which of the following actions should the nurse take?

Instruct the client to expect ringing in the ears.

Place the client in restraints for 1 hour.

Initiate fall precautions for the client.

Repeat the dose in 15 minutes if the client is still anxious.

Answer and Explanation

The Correct Answer is C

Choice A reason: Ringing in the ears is not a common side effect of lorazepam. This medication is more likely to cause drowsiness or dizziness, which could increase the risk of falls.

Choice B reason: Restraints should only be used as a last resort when all other options have been exhausted and the client is a danger to themselves or others. Lorazepam is used to reduce anxiety, not to sedate to the point where restraints would be necessary.

Choice C reason: Initiating fall precautions is a prudent nursing action after administering lorazepam, especially if given intramuscularly, as the client may experience drowsiness or dizziness, increasing the risk of falls.

Choice D reason: Repeating the dose in 15 minutes is not recommended. The effects of lorazepam should be monitored, and additional doses should be administered based on the client's response and as prescribed by the healthcare provider.

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Correct Answer is B

Explanation

Choice A reason: This statement may seem supportive, but it does not address the immediate safety concerns for a client with suicidal ideations and a verbalized plan. Submitting a request for privacy does not mitigate the risk of harm the client may pose to themselves.

Choice B reason: This is the most appropriate response because it directly addresses the safety of the client, which is the primary concern in this situation. It communicates care and concern while also reinforcing the need for observation due to the risk of suicide.

Choice C reason: While safety contracts can be a part of a comprehensive treatment plan, they are not foolproof and should not replace close observation for a client who has expressed suicidal ideations and has a plan. Relying solely on a contract in this situation could be dangerous.

Choice D reason: This statement is factual in that medication levels need to be therapeutic; however, it does not directly address the immediate risk of suicide. Constant observation is required regardless of medication levels if a client has verbalized a plan for suicide.

A. Blood glucose 256 mg/dL (74 to 106 mg/dL) B. WBC count 6,000/mm³ (5,000 to 10,000/mm³) C. Platelets 250,000/mm³ (150,000 to 400,000/mm³) D. Sodium 140 mEq/L (136 to 145 mEq/L)

Correct Answer is A

Explanation

Choice A reason: A blood glucose level of 256 mg/dL is significantly higher than the normal range and could indicate hyperglycemia, which is a serious side effect of risperidone. The provider should be notified immediately to manage this potential complication.

Choice B reason: A WBC count of 6,000/mm³ is within the normal range and does not typically warrant concern or the need to notify the provider.

Choice C reason: A platelet count of 250,000/mm³ is also within the normal range and is not indicative of an adverse reaction to risperidone.

Choice D reason: A sodium level of 140 mEq/L falls within the normal range and is not a cause for alarm in the context of risperidone therapy.

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A nurse is caring for a client who just received lorazepam 1 mg IM for anxiety. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is under observation for suicidal ideations and has verbalized a suicide plan. The client demands privacy and to be left alone. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

A nurse is reviewing laboratory results of a client who has schizophrenia and is taking risperidone. For which of the following findings should the nurse notify the provider?

Correct Answer is A

Explanation

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