A nurse is caring for a client who just received lorazepam 1 mg IM for anxiety. Which of the following actions should the nurse take?

Choice A reason: Ringing in the ears (tinnitus) isn’t a common lorazepam side effect; sedation, confusion, or dizziness are. Instructing this misinforms the client, potentially causing undue worry. Post-IM administration focuses on monitoring actual effects, not unrelated symptoms. This action lacks relevance to lorazepam’s profile, so it’s incorrect. Choice B reason: Restraints for 1 hour post-lorazepam assume behavioral control needs without evidence of aggression. This violates least restrictive care, risking harm or agitation in an anxious client. Lorazepam calms, not escalates, behavior, making restraints unnecessary and unethical unless danger emerges. Choice C reason: Repeating lorazepam in 15 minutes risks oversedation, as 1 mg IM peaks in 60-90 minutes, needing time to assess efficacy. Protocol requires monitoring, not immediate redosing, absent severe symptoms. This premature action endangers respiratory safety, so it’s not appropriate. Choice D reason: Lorazepam’s sedative effects (drowsiness, dizziness) increase fall risk post-IM injection, especially in anxiety where mobility may persist. Initiating precautions like bed alarms or assistance ensures safety, a priority after benzodiazepine use. This action aligns with standard care, making it the correct choice.