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

This is because itching is a subjective assessment finding, which means it is based on the personal experience, view or feeling of the

patient. The other choices are objective assessment findings, which means they are based on observable or measurable data that the nurse can collect.

For example:

Choice A is wrong because hives are a visible skin reaction that can be seen and measured by the nurse.

Choice C is wrong because vomiting is an observable action that can be verified and recorded by the nurse.

Choice D is wrong because abdominal distension is a measurable change in the size or shape of the abdomen that can be assessed by the nurse.

Normal ranges for objective assessment findings may vary depending on the source and context, but some possible examples are:

• Hives: No hives or rashes on the skin are normal.
• Vomiting: No vomiting or nausea are normal.
• Abdominal distension: Normal abdominal girth for adults ranges from 68 to 100 cm (27 to 40 inches).

“My medication will be given at the scheduled times to best manage my pain.” This statement demonstrates understanding of the pain management plan because it shows that the client knows the importance of preventing pain from becoming severe by taking medication regularly. Scheduled administration of analgesics is more effective than administering them on demand.

Choice A is wrong because it implies that the client will wait until the pain is severe before asking for medication, which can make it harder to control.

Choice C is wrong because it suggests that the client expects to receive inadequate pain relief due to their history of opioid abuse, which is not ethical or evidence-based.

Choice D is wrong because it indicates that the client believes they will be denied any narcotics for pain, which is also not ethical or

evidence-based. Clients with a history of opioid abuse can still receive opioids for acute pain, but they may need higher doses or more frequent administration to achieve adequate analgesia.

Normal ranges for vital signs are as follows: respiratory rate 12-20 breaths per minute, heart rate 60-100 beats per minute, blood pressure 120/80 mmHg, temperature 36.5-37.5°C (97.7- 99.5°F).