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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Engaging in stressful activities before bedtime can increase alertness and make it difficult to fall asleep. The nurse's recommendation to avoid stress before sleep is in line with good sleep hygiene practices that promote relaxation and readiness for sleep.
Choice B reason: Exercising too close to bedtime can be stimulating and may hinder the ability to fall asleep. It is generally recommended to finish exercising at least 3 hours before bedtime to allow the body to wind down.
Choice C reason: Taking long naps, especially in the afternoon, can disrupt nighttime sleep patterns. For individuals with insomnia, it is better to avoid naps or limit them to early in the day and for short durations.
Choice D reason: Watching television in bed can negatively impact sleep due to the light from the screen and the content, which can be stimulating. It is recommended to keep the bedroom environment conducive to sleep, which means no screens before bedtime.
Correct Answer is D
Explanation
Choice A reason: Witnessing an informed consent is a legal process that typically requires a licensed nurse or healthcare provider to ensure that the client fully understands the procedure and its risks. It is not appropriate to delegate this task to assistive personnel.
Choice B reason: Explaining the benefits of light therapy involves providing health education, which should be done by a licensed nurse or healthcare provider who has the necessary knowledge and training to ensure accurate information is conveyed.
Choice C reason: Discussing the adverse effects of medications is part of medication education and should be conducted by a licensed nurse or healthcare provider. Assistive personnel are not trained to provide this level of detailed medical information.
Choice D reason: Participating in solitary activities does not require clinical judgment and can be safely delegated to assistive personnel. This task involves engaging the client in activities that can help manage their mania and provide a therapeutic environment.
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