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 ["B","C"]

Explanation

Rationale

A. High in sodium due to pickling, which is not suitable for someone with hypertension.

B. Recommended because fresh fruits are low in sodium and high in potassium and other nutrients beneficial for managing blood pressure.

C. Recommended because they are low in sodium and rich in potassium, fiber, and nutrients that support cardiovascular health.

D. Cottage cheese is high in sodium and should be avoided or consumed in moderation.

E. Generally high in sodium, which should be limited or avoided in the diet of someone with hypertension.

A. Serum albumin. B. Neutrophil count. C. Serum blood glucose (BG) level. D. Hematocrit.

Correct Answer is B

Explanation

Rationale

A. Although low serum albumin levels can impact wound healing, they are not directly related to the presence of purulent drainage.

B. Neutrophils are a type of white blood cell involved in the body's immune response, particularly against bacterial infections. An elevated neutrophil count (neutrophilia) can indicate an acute infection or inflammation, including in wounds.

C. High blood glucose levels can predispose the client to infections, including wound infections. While it's important to monitor blood glucose levels, it is less directly relevant to the immediate concern of purulent drainage from the burn wound.

D. Hematocrit measures the proportion of red blood cells in the blood and is used to assess hydration status and oxygen-carrying capacity. In burn patients, changes in hematocrit can indicate fluid shifts and potential dehydration. Fluid shifts and dehydration can influence wound healing and overall patient condition but are not directly related to the presence of purulent drainage.

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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

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? Select all that apply.

Correct Answer is ["B","C"]

Explanation

While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is B

Explanation

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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.