patient with depression reports feeling more suicidal after starting an antidepressant.
What should the nurse do?

Choice A rationale

Benzodiazepines, such as diazepam, are central nervous system depressants. Their primary action is to enhance the effect of the neurotransmitter GABA, which results in sedative, anxiolytic, and muscle-relaxant properties. This mechanism of action often leads to a decrease, not an increase, in blood pressure. Therefore, hypertension is not an anticipated adverse effect.

Choice B rationale

Benzodiazepines enhance the inhibitory effects of GABA throughout the central nervous system, including the brainstem respiratory centers. This can lead to a significant dose-dependent depression of respiratory drive. This effect is particularly dangerous when these medications are combined with other CNS depressants like opioids or alcohol, leading to potentially fatal respiratory arrest.

Choice C rationale

Benzodiazepines are known to cause central nervous system depression, leading to sedation and decreased psychomotor activity. They are prescribed to treat anxiety and insomnia, and their intended effects are calming and sedating. Hyperactivity, which is an increase in activity and restlessness, is the opposite of the expected pharmacological effect and is not a typical adverse reaction.

Choice D rationale

Benzodiazepines are known to decrease alertness and cause drowsiness due to their central nervous system depressant effects. This is a common and expected side effect, especially at higher doses or with initial use. Advising a patient about decreased alertness is essential for safety, as it can impair their ability to perform tasks requiring focus.

Choice A rationale

Giving the insulin is not safe because there is a possibility the patient has already received it, even though the record is not signed. Administering a second dose of insulin could lead to hypoglycemia, a life-threatening condition where the blood glucose level drops dangerously low, causing symptoms like confusion, seizures, and unconsciousness.

Choice B rationale

Holding the insulin is the initial safe action, but simply holding it doesn't resolve the issue and leaves the patient's care plan incomplete. The primary concern is the potential for a double dose and the lack of proper documentation. The problem requires a more formal and structured response than simply holding the medication and moving on.

Choice C rationale

Contacting the night nurse is an option, but it is not the most immediate or appropriate action. The night nurse may be asleep or unreachable. The nurse on duty is responsible for the patient's safety and should follow proper chain of command and reporting protocols to resolve the issue promptly and ensure patient safety.

Choice D rationale

This situation involves a medication discrepancy, a potential medication error, and a significant safety risk to the patient. Reporting it to the nursing supervisor is the correct and necessary action. The supervisor can initiate a formal investigation, ensure the patient is safe, and address the documentation issue to prevent future errors.