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 C

Explanation

Choice A reason: While stress reduction techniques are important, they are not the immediate priority when a client is currently being aggressive.

Choice B reason: Role modeling is a long-term strategy and not appropriate for immediate intervention during an aggressive incident.

Choice C reason: This is the priority action to assess the risk of harm to others and to take necessary steps to ensure safety for all clients in the facility.

Choice D reason: Making a list is a reflective activity that may be part of a treatment plan but is not the priority action during an episode of aggression.

A. "Watch television to facilitate falling asleep." B. "Exercise at least 3 hours before bedtime." C. "Consume your evening meal 1 hour before bedtime." D. "Take an hour-long nap daily."

Correct Answer is B

Explanation

Choice A reason: Watching television before bedtime can be stimulating and interfere with the ability to fall asleep. The blue light emitted by screens can also disrupt the body's natural sleep-wake cycle.

Choice B reason: Regular exercise, particularly when done earlier in the day, can help reduce anxiety and improve sleep quality. However, it's important to avoid vigorous exercise close to bedtime as it can be too stimulating.

Choice C reason: Consuming the evening meal too close to bedtime can cause indigestion and interfere with sleep. It's better to finish eating at least 2-3 hours before going to bed.

Choice D reason: Taking long naps, especially later in the day, can make it more difficult to fall asleep at night. If naps are necessary, they should be short and not too close to bedtime.

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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

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