Nokea
A client is prescribed lorazepam. The nurse understands that this drug can be given by which route? Select all that apply.
- A. Intramuscular
- B. Oral
- C. Transdermal
- D. Intravenous
- E. Rectal
Correct Answer: A,B,D
Rationale: Lorazepam can be administered to a client via the oral, IM, and IV routes.
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A nurse is preparing a teaching plan for a client who is prescribed an anxiolytic. As part of the plan, the nurse addresses medications that should be avoided to reduce the risk of increased CNS depression and sedation. Which of the following would the nurse include? Select all that apply.
- A. Alcohol
- B. Analgesics
- C. Digoxin
- D. Tricyclic antidepressants
- E. Antipsychotics
Correct Answer: A,B,D,E
Rationale: Alcohol, analgesics, tricyclic antidepressants, and antipsychotics should be used with caution with anxiolytics due to increased CNS depression and increased risk of sedation.
A client is hospitalized and is prescribed diazepam. Before administering the drug, which of the following information should the nurse obtain? Select all that apply.
- A. Complete medical history
- B. Mental status exam
- C. Anxiety level
- D. Pain assessment
- E. Medication history
Correct Answer: A,B,C
Rationale: Before starting anxiolytic therapy in a hospitalized client, the nurse obtains a complete medical history, including mental status and anxiety level.
A client who is receiving a benzodiazepine tells the nurse that his mouth feels really dry. Which of the following would the nurse include in the teaching plan for this client?
- A. Try drinking about 8 ounces of water at least every 2 hours.
- B. Sucking on hard sugarless candy might help you.
- C. Make sure you eat a lot of green leafy vegetables.
- D. Change your position slowly as you get out of bed.
Correct Answer: B
Rationale: For dry mouth, the nurse should suggest sucking on hard, sugarless candies or chewing sugarless gum. Frequent sips of water would also help, but drinking 8 ounces of water every 2 hours could lead to fluid overload. Eating green leafy vegetables would help with constipation. Changing positions slowly would be appropriate if the client reported dizziness or lightheadedness.
A client is prescribed a benzodiazepine as treatment for anxiety. After administration of the drug, the client reports dizziness and lightheadedness. Which nursing diagnosis would the nurse identify as a priority?
- A. Impaired Comfort
- B. Risk for Injury
- C. Ineffective Coping
- D. Deficient Knowledge
Correct Answer: B
Rationale: Dizziness and lightheadedness place the client at risk for falls; therefore, Risk for Injury would be the priority. Impaired Comfort would be appropriate if the client reported problems such as dry mouth or constipation. Ineffective Coping would be appropriate if the client reported continued feelings of anxiety. There is no evidence to suggest that the client lacks knowledge of the drug therapy.
A nurse suspects that a client is experiencing anxiety. Which physical assessment findings would support the nurse's suspicion? Select all that apply.
- A. Hypotension
- B. Decreased respiratory rate
- C. Increased muscle tension
- D. Pale skin
- E. Bradycardia
Correct Answer: C,D
Rationale: Physiological manifestations of anxiety can include hypertension, tachycardia, increased rate and depth of respirations, increased muscle tension, and cool, pale skin.