Patient Data

Exhibits

For each action, identify if it is indicated or not indicated when monitoring the effects of lorazepam administration. Each row must have one response action selected.

Count the respirations.

Listen for heart palpitations.

Assess for constipation.

Evaluate client for motor coordination.

Observe level of consciousness.

Monitor for drowsiness.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Rationale:

Count the respirations: Lorazepam is a benzodiazepine that can cause respiratory depression, especially when given IV. Regular monitoring of respiratory rate helps detect hypoventilation early.
Listen for heart palpitations: While the client initially had atrial tachycardia, monitoring palpitations is not a priority in evaluating lorazepam’s effectiveness, which focuses more on CNS and respiratory status.
Assess for constipation: Constipation is not an acute or common side effect associated with single-dose IV lorazepam. It is not relevant in short-term monitoring.
Evaluate client for motor coordination: Benzodiazepines like lorazepam may impair psychomotor function. Assessing coordination can help monitor CNS depressant effects and safety.
Observe level of consciousness: Altered LOC is a common side effect of lorazepam due to its sedative properties. Ongoing neurological checks are essential.
Monitor for drowsiness: Drowsiness is a common and expected effect of lorazepam. Monitoring helps determine if the sedative effect is appropriate or excessive.

Nursing Test Bank

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Correct Answer is ["A","B","C","D","E"]

Explanation

Rationale:
A. Encourage activity as tolerated: Gradual mobilization supports respiratory function, circulation, and muscle strength after prolonged intubation. Activity also helps reduce the risk of complications like atelectasis and deep vein thrombosis.

B. Assess ability to swallow solids and liquids: After extended intubation, clients are at risk for dysphagia, which can lead to aspiration pneumonia. A swallowing assessment is necessary to ensure safety before resuming a regular oral diet.

C. Assist client with active range of motion: Prolonged immobility in the ICU often leads to deconditioning and muscle weakness. Assisting with range of motion exercises promotes circulation, prevents contractures, and maintains joint flexibility.

D. Reinforce deep breathing exercises: Deep breathing promotes alveolar expansion, improves oxygenation, and prevents postoperative complications such as pneumonia or atelectasis, which are particularly concerning after extubation and in clients with COPD.

E. Obtain dietary consult for meal supplements: Poor appetite post-extubation can contribute to malnutrition and delayed recovery. A dietary consult ensures the client receives adequate caloric and protein intake through appropriate supplements.

A. Encouraging the client to join a support group. B. Allowing the client to ventilate feelings. C. Shaking the client's hand during an introduction. D. Wearing gloves when interviewing the client.

Correct Answer is C

Explanation

Rationale:
A. Encouraging the client to join a support group: While beneficial, referring the client to a support group does not immediately address the client's psychosocial need for acceptance in the nurse-client interaction. Acceptance should first be modeled directly by caregivers.

B. Allowing the client to ventilate feelings: This addresses emotional support but does not necessarily promote acceptance. The client may still feel socially isolated or judged if the nurse maintains physical distance or acts hesitantly.

C. Shaking the client's hand during an introduction: This action demonstrates respect, inclusion, and nonjudgmental care. It helps normalize the interaction and signals to the client that the nurse does not view their skin condition as repulsive or infectious. Such gestures reduce stigma and build trust.

D. Wearing gloves when interviewing the client: Gloving when unnecessary can send a message that the client is contaminated. For non-contact interviews, gloves are not required and may make the client feel rejected or judged. It contradicts acceptance goals.

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Patient Data Exhibits For each action, identify if it is indicated or not indicated when monitoring the effects of lorazepam administration. Each row must have one response action selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult with pneumonia and an exacerbation of chronic obstructive pulmonary disease (COPD) was intubated for 14 days and was sucessfully extubated yesterday. Currently, the client has a weak cough and poor appetite. Which intervention(s) should the nurse implement? Select all that apply.

Correct Answer is ["A","B","C","D","E"]

Explanation

The nurse is assigned to care for a client diagnosed with psoriasis. Which behavior by the nurse addresses this client's psychosocial need for acceptance?

Correct Answer is C

Explanation

The public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal?

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The nurse is planning an educational session for new parents on ways to prevent sudden infant death syndrome (SIDS). Which information is most important to provide parents of newborns and infants?

Patient Data

Exhibits

For each action, identify if it is indicated or not indicated when monitoring the effects of lorazepam administration. Each row must have one response action selected.