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Exhibits

The nurse reviews the physician's orders for clonazepam and gives the medication as ordered. What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.

Screen for orthostatic hypotension

Provide oral care at least twice a day

Monitor calcium levels

Assess mental status regularly

Assist the client to the bathroom

Have an opioid agonist at the bedside

Answer and Explanation

Correct Answer : A,B,D,E

Nursing Interventions for Client Starting Clonazepam:

The following nursing interventions are appropriate for the client starting clonazepam 0.25 mg PO every 12 hours:

a. Screen for orthostatic hypotension:

Rationale:

Clonazepam, like other benzodiazepines, can cause central nervous system (CNS) depression, which can lead to hypotension, particularly orthostatic hypotension. This occurs when blood pressure drops suddenly upon standing due to impaired autonomic nervous system regulation.
Screening for orthostatic hypotension involves measuring the client's blood pressure and heart rate while lying down and then again after standing for 3 minutes. A significant drop in blood pressure (systolic decrease of 20 mmHg or diastolic decrease of 10 mmHg) or increase in heart rate (over 20 beats per minute) indicates orthostatic hypotension.
Monitoring for orthostatic hypotension is crucial to prevent falls and other complications, especially in older adults or those with pre-existing cardiovascular conditions.

b. Provide oral care at least twice a day:

Rationale:

Clonazepam can cause dry mouth as a side effect, which can increase the risk of cavities, gum disease, and oral infections.
Regular oral care helps to remove plaque and bacteria, promoting oral hygiene and preventing complications. Providing oral care at least twice a day, especially before bedtime and upon waking, is essential.

d. Assess mental status regularly:

Rationale:

Clonazepam, while indicated for anxiety and insomnia, can paradoxically cause agitation, confusion, and even hallucinations in some individuals, particularly older adults or those with pre-existing psychiatric conditions.
Regular assessment of mental status helps to identify any adverse behavioral or cognitive changes early on. This includes monitoring for anxiety, depression, suicidal ideation, confusion, disorientation, hallucinations, and changes in sleep patterns.

e. Assist the client to the bathroom:

Rationale:

Clonazepam can cause drowsiness and dizziness, which can increase the risk of falls, especially in older adults or those with impaired mobility.
Assisting the client to the bathroom and providing support during toileting activities helps to prevent falls and injuries.

Choices not included:

c. Monitor calcium levels:

There is no specific indication for monitoring calcium levels with clonazepam use.

f. Have an opioid agonist at the bedside:

Clonazepam is not indicated for pain management and does not interact significantly with opioid analgesics. Therefore, having an opioid agonist readily available is not a necessary intervention for clonazepam initiation.

Additional Considerations:

Educate the client about the potential side effects of clonazepam, including drowsiness, dizziness, dry mouth, and cognitive changes.
Advise the client to avoid alcohol and other CNS depressants while taking clonazepam, as this can increase the risk of sedation and respiratory depression.
Instruct the client to take clonazepam exactly as prescribed and not to stop taking it abruptly, as this can lead to withdrawal symptoms.
Monitor the client's sleep patterns and adjust the medication schedule if necessary.

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Correct Answer is C

Explanation

Imbalanced Nutrition: less than body requirements would be the nursing problem with the highest priority for an adolescent with anorexia nervosa. Anorexia nervosa is characterized by a severe restriction of food intake leading to a significantly low body weight, which can have serious physical and psychological consequences. Therefore, addressing the client's malnutrition and promoting adequate nutrition intake is crucial to prevent further complications. Disturbed Body Image, Interrupted Family Processes, and Noncompliance with treatment regimen are important nursing problems to address, but they are secondary to the client's malnutrition.

A. Weigh the client and report any weight gain. B. Reporting any client complaints of pain or discomfort. C. Evaluate the client for sleep disturbances. D. Note and report the client's food and liquid intake during meals and snacks. E. Assess the client for weakness and fatigue.

Correct Answer is ["A","B","D"]

Explanation

A) Correct- Weighing the client and reporting any weight gain is a routine measurement that can be safely performed by the UAP. Weight gain can be an important indicator of fluid retention, a common issue in Cushing's syndrome.
B) Correct- Reporting any client complaints of pain or discomfort is important for monitoring the client's well-being and promptly addressing any potential issues.
C) Incorrect- Evaluating the client for sleep disturbances involves assessing the client's sleep patterns, quality, and potential disruptions. This requires nursing judgment and a deeper understanding of the client's condition and potential contributing factors, so it's not appropriate to delegate this task to the UAP.
D) Correct- Noting and reporting the client's food and liquid intake during meals and snacks is part of monitoring the client's nutritional status, which is an appropriate task for the UAP.
E) Incorrect- Assessing the client for weakness and fatigue involves a more comprehensive evaluation of the client's physical and physiological status, which requires nursing expertise. The nurse should directly assess and interpret these symptoms in the context of Cushing's syndrome to provide appropriate interventions.

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Exhibits The nurse reviews the physician's orders for clonazepam and gives the medication as ordered. What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.

Nursing Interventions for Client Starting Clonazepam:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority?

Correct Answer is C

Explanation

The nurse is managing the care of a client with Cushing's syndrome. Which intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

The nurse is caring for a client newly diagnosed with emphysema. The nurse should prioritize which potential complication?

The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?

The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure?

Exhibits

The nurse reviews the physician's orders for clonazepam and gives the medication as ordered. What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.