A client being treated for somatoform disorder with psychotherapy and benzodiazepine medica-tion approaches the nurse and says he feels dizzy and weak. The nurse's initial intervention should be to:
1. Tell the client to sit and breathe deeply
2. Administer prn alprazolam (Xanax)
3. Measure the client's vital signs
4. Instruct the client in use of imagery
ANS: 3
Because the client's symptoms could be related to benzodiazepine therapy, the nurse should measure pulse and blood pressure to assess for orthostatic hypotension. Options 1 and 4: These might be possible strategies when symptoms have been determined to be of psychogenic origin. Option 2: The client's symptoms may be due to benzodiazepine side effects, so giving more is inadvisable until assessment is complete.
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