Patient Data
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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Rationale for Correct Choices:
- Sleeping difficulty: The client reports insomnia, a core symptom of post-traumatic stress disorder (PTSD) and depression. Sleep disturbances are common among individuals with trauma exposure and are particularly concerning when paired with suicidal ideation.
- Hypervigilance: The client's constant surveying of the environment and being easily startled are hallmark signs of hypervigilance. This symptom reflects heightened arousal often seen in PTSD, especially in veterans who have experienced combat trauma.
Rationale for Incorrect Choices:
- Withdrawn mood: While the client appears quiet and withdrawn, this behavior is more observational than subjective. The question asks for subjective symptoms, which are the client’s personal experiences rather than behaviors noted by others.
- Alcohol on breath: The presence of alcohol on the breath is an objective clinical finding, not a subjective symptom reported by the client. Although relevant to her condition, it doesn’t fulfill the criteria specified in the prompt.
- Blood pressure of 144/92 mmHg: This is an objective vital sign and not a subjective symptom. Elevated blood pressure may be due to anxiety but is not something the client reports feeling.
- Nightmares: Though she has nightmares, this was part of the background history already acknowledged. Hypervigilance is more acute and directly observable during this clinical encounter.
- Latency of response: While the client requires prodding to give answers, this is an observed behavior and not a reported internal experience, so it does not qualify as a subjective symptom.
- Respirations of 20 breaths/minute: This is an objective clinical measurement. It may suggest anxiety, but it is not subjectively reported by the client.
Correct Answer is B
Explanation
Rationale:
A. Meningitis B: This vaccine is not routinely indicated during or after pregnancy unless there is a specific risk factor or outbreak. It is not a standard postpartum immunization.
B. Measles, mumps, rubella: The MMR vaccine is live and contraindicated during pregnancy due to potential fetal harm. It should be given postpartum if the client is non-immune to prevent future infection.
C. Diphtheria, pertussis, tetanus: The Tdap vaccine is safe and recommended during each pregnancy, ideally between 27 and 36 weeks gestation, to provide passive immunity to the newborn.
D. Influenza vaccine: Inactivated influenza vaccine is recommended during pregnancy to protect both mother and baby. It should not be delayed until after pregnancy.
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