The nurse reviewed the nurses’ notes, provider’s note, and vital signs at 0415.

Exhibits

Which of the following interventions should the nurse include in the client’s care? Select the three interventions the nurse should implement.

Choice A reason:
The statement "Repeat the dose in 15 minutes if the client is still anxious" is not appropriate. Lorazepam is a benzodiazepine that can cause significant sedation and central nervous system depression. Repeating the dose too soon can increase the risk of severe sedation, respiratory depression, and other adverse effects.

Choice B reason:
The statement "Initiate fall precautions for the client" is the correct response. Lorazepam can cause dizziness, drowsiness, and impaired coordination, increasing the risk of falls, especially in older adults. Implementing fall precautions is essential to ensure the client's safety.

Choice C reason:
The statement "Instruct the client to expect ringing in the ears" is incorrect. Tinnitus (ringing in the ears) is not a common side effect of lorazepam. Common side effects include drowsiness, dizziness, and muscle weakness.

Choice D reason:
The statement "Place the client in restraints for 1 hour" is inappropriate. Restraints should only be used as a last resort when the client poses a danger to themselves or others and when less restrictive measures have failed.

Neurologic:

• Fatigue after being awake a few hours: Fatigue can be a symptom of various conditions, including anemia, depression, sleep disorders, and others. It’s important to investigate further to determine the cause.
• Feels “restless”: Restlessness can be a symptom of mental health disorders like anxiety or physical conditions like restless leg syndrome. Further evaluation is needed.
• Difficulty concentrating on work and other activities: This could be a symptom of stress, anxiety, depression, or other mental health conditions. It could also be related to the client’s reported fatigue.
• Difficulty falling asleep and wakes up “after a few hours”: This could indicate a sleep disorder such as insomnia, which could also be contributing to the client’s fatigue and difficulty concentrating.
• Worried about work and family needs: This could indicate stress or anxiety, which may need to be addressed with stress management strategies or counseling.

Musculoskeletal:

• Reports muscles feel tight and achy: This could be due to overuse, stress, or a medical condition like fibromyalgia. Further investigation is needed.

Gastrointestinal:

• Bowel sounds distant: This could indicate a slow-down in the digestive process and may require further investigation.

Cardiovascular:

• Apical 92/min and regular: While this is within the normal range, it’s at the higher end. If the client isn’t physically active, it might be worth investigating further.

Respiratory:

• Occasional dry cough: While this could be due to something benign like allergies, it could also be a symptom of a respiratory condition. If it persists, it should be investigated further.