The nurse is assessing a client presenting with diazepam intoxication.
What signs and symptoms are consistent with benzodiazepine intoxication? Select all that apply.

Using teach back method to assess understanding. This method involves asking the client to repeat back the information or demonstrate the skill that was taught, which helps to evaluate their comprehension and retention.

It also allows the nurse to correct any misunderstandings and reinforce key points.

Choice A is wrong because teaching handouts are written on an eighth grade reading level may not be appropriate for older adult clients who may have lower literacy levels or cognitive impairments. The nurse should use simple, common language and large-print handouts that reflect the verbal information presented.

Choice C is wrong because the teaching plan is based on nutrition, medications, and safety may not address the individual needs and preferences of the older adult clients. The nurse should consider the preadmission functional abilities, health goals, and learning styles of each client when developing the plan of care.

Choice D is wrong because websites, video chats, and cell phone applications are introduced for learning may not be suitable or accessible for older adult clients who may have limited technology skills or sensory impairments. The nurse should use visual aids, face-to-face communication, and written instructions to enhance learning.

A two-day postoperative client who has a large abdominal incision and says, “Something feels like it just popped open after I practiced my coughing”. This client may have a dehiscence or separation of the surgical wound, which is a serious complication that requires immediate attention.

The nurse should evaluate this client first and notify the surgeon.

Choice B is wrong because bile-colored fluid draining from a nasogastric tube is an expected finding after abdominal surgery and does not indicate an urgent problem.

The nurse should monitor the client’s fluid and electrolyte balance and provide antiemetics as needed.

Choice C is wrong because a three-day postoperative client who has an ileostomy and reports the need to have a bowel movement may have a paralytic ileus or a temporary cessation of bowel motility. This is a common postoperative complication that usually resolves within 72 hours.

The nurse should assess the client’s bowel sounds, abdominal distension, and ostomy output and encourage early mobilization and oral intake as tolerated.

Choice D is wrong because a three-day postoperative client who is receiving intravenous antibiotics for a wound infection may have a surgical site infection or an infection that occurs within 30 days of surgery. This is a preventable complication that can be managed with antibiotics, wound care, and infection control measures.

The nurse should monitor the client’s vital signs, wound appearance, and laboratory values and educate the client on signs and symptoms of infection.