Exhibits

The nurse reviews the healthcare providers (HCP) prescription for clonazepam and gives the medication as prescribed.

Which nursing intervention(s) is/are appropriate for the client starting clonazepam? Select all that apply.

Assess mental status regularly

Provide oral care at least twice à day

Monitor calcium levels

Have an opioid agonist at the bedside

Assist the client to the bathroom

Screen for orthostatic hypotension

Answer and Explanation

Correct Answer : A,B,E,F

A.   Clonazepam is a benzodiazepine used primarily for anxiety disorders and can affect mental status, including cognition and level of alertness. Regular assessment helps monitor for any changes in mental status, such as drowsiness, confusion, or sedation, which are potential side effects of clonazepam.
B.   This intervention helps maintain oral hygiene, which is important when a client is taking medications orally. Benzodiazepines like clonazepam can cause dry mouth as a side effect, which can contribute to oral hygiene issues such as increased risk of dental caries or oral infections.
C.   Clonazepam itself does not directly affect calcium levels. Monitoring calcium levels is not a routine nursing intervention specifically related to clonazepam administration. This option is not appropriate in this context.
D.   Clonazepam is not an opioid and does not directly interact with opioids in a way that would necessitate having an opioid agonist at the bedside. This option is not relevant for a client starting clonazepam.
E.   Clonazepam can cause dizziness and impair coordination, especially when starting the medication or with dose changes. Assisting the client to the bathroom helps prevent falls and ensures safety, particularly if the client experiences dizziness or sedation.
F.   Benzodiazepines like clonazepam can cause hypotension (low blood pressure), which may exacerbate upon standing (orthostatic hypotension). Screening involves checking blood pressure and heart rate in different positions (lying, sitting, standing) to detect orthostatic changes. This is important to prevent falls and other complications.

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Correct Answer is C

Explanation

Rationale

A. This finding suggests that the skin has already broken down, indicating a more advanced stage of pressure injury rather than an early indication. The presence of broken skin typically indicates at least a Stage 2 pressure injury according to the staging system.

B. This description suggests the presence of a deep tissue injury (DTI), which is a late sign of pressure injury.

C. This is indicative of a stage I pressure injury, where the skin is still intact but shows signs of redness that does not blanch with pressure. This stage precedes the actual breakdown of skin seen in more advanced pressure injuries.

D. This finding describes a superficial wound with clear margins, suggesting a Stage 2 pressure injury. It is more advanced than the early signs typically sought for early intervention.

A. Clarify that all STIs are transmitted through sexual intercourse. B. Explain that reinfections occur from sex with untreated partners. C. Provide counseling that most contraceptives protect against infection. D. Emphasize that using safe sex practices removes the risk of STIs.

Correct Answer is B

Explanation

Rationale

A. This statement is partially true as most sexually transmitted infections (STIs), including syphilis, are primarily transmitted through sexual intercourse. However, not all STIs are exclusively transmitted through sexual contact.

B. Syphilis is caused by the bacterium Treponema pallidum and can be transmitted through direct contact with a syphilitic sore (chancre) during vaginal, anal, or oral sex. If a person has syphilis and engages in unprotected sex with a partner who is not treated, they can potentially contract or transmit the infection again, leading to reinfection.

C. While contraceptives such as condoms provide protection against unintended pregnancy and some STIs, including syphilis, they do not offer complete protection against all STIs. Condoms are effective in reducing the risk of transmission of syphilis when used consistently and correctly, but they are not 100% protective.

D. Using safe sex practices, such as consistent and correct use of condoms, reduces the risk of acquiring or transmitting STIs, including syphilis. Safe sex practices also include mutual monogamy and regular testing for STIs, especially for those who have multiple sexual partners or engage in high-risk sexual behaviors.

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Exhibits The nurse reviews the healthcare providers (HCP) prescription for clonazepam and gives the medication as prescribed. Which nursing intervention(s) is/are appropriate for the client starting clonazepam? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client admitted with pneumonia and on bedrest has not had the strength to perform self care. Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

Correct Answer is C

Explanation

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide?

Correct Answer is B

Explanation

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Exhibits Which other treatment(s) might be helpful for this client? Select all that apply.

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Exhibits

The nurse reviews the healthcare providers (HCP) prescription for clonazepam and gives the medication as prescribed.

Which nursing intervention(s) is/are appropriate for the client starting clonazepam? Select all that apply.