During a morning group meeting, a client raises concern that they cannot sleep at night due to the noises coming from the nurse’s station. The nurse in the meeting interrupts and states, “I’ll handle this matter. Let’s move on.” The nurse is demonstrating which type of leadership style?

Choice A Reason:

Administer the medication with food.

Administering clonazepam with food can help reduce gastrointestinal discomfort, but it is not the most critical consideration. While it is beneficial to minimize potential side effects like nausea, it does not address the primary safety concerns associated with clonazepam use.

Choice B Reason:

Administer the medication to the client at night to avoid daytime sedation.

Administering clonazepam at night can help avoid daytime sedation, which is a common side effect of benzodiazepines. However, this is not the most critical safety concern. While managing sedation is important, it does not address the potential for more serious interactions and risks.

Choice C Reason:

Encourage the client to avoid drinking alcohol when taking this medication.

This is the correct response. Alcohol can significantly increase the sedative effects of clonazepam, leading to dangerous levels of sedation, respiratory depression, and even death. It is crucial to educate clients about the risks of combining alcohol with benzodiazepines to prevent potentially life-threatening interactions.

Choice D Reason:

Assess for history of smoking.

While assessing for a history of smoking is part of a comprehensive health assessment, it is not the most critical consideration when administering clonazepam. Smoking does not have the same immediate and severe interaction risks with clonazepam as alcohol does.

The correct answer is a, b.

Choice A Reason:

The statement “Organize clinical observations” is correct. One of the primary functions of the Mental Status Exam (MSE) is to systematically organize clinical observations. This includes assessing the client’s appearance, behavior, mood, and cognitive functions. By organizing these observations, healthcare providers can create a comprehensive picture of the client’s current mental state, which is crucial for diagnosis and treatment planning.

Choice B Reason:

The statement “Obtain information about the client’s medical history” is correct. The MSE often involves gathering detailed information about the client’s medical history, including past mental health issues, treatments, and any relevant medical conditions. This information helps in understanding the client’s baseline mental status and identifying any changes or abnormalities. It also aids in creating an effective treatment plan tailored to the client’s specific needs.

Choice C Reason:

The statement “Establish limit setting” is incorrect. While limit setting is an important aspect of managing certain mental health conditions, it is not a primary function of the MSE. Limit setting typically involves establishing boundaries and rules to manage behaviors, which is more relevant in therapeutic settings rather than during the assessment phase. The MSE focuses on evaluating the client’s current mental state rather than setting behavioral limits.

Choice D Reason:

The statement “Determine the client’s IQ” is incorrect. The MSE is not designed to measure a client’s intelligence quotient (IQ)4. Instead, it assesses cognitive functions such as memory, attention, and orientation. IQ tests are specialized assessments that require specific tools and are conducted separately from the MSE. The MSE provides a general overview of cognitive functioning but does not quantify intelligence.