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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 B

Explanation

In this situation, the client has a fingerstick glucose level of 35 mg/dL (1.94 mmol/L) and is alert but diaphoretic. The charge nurse should take the following action:

Give the client a glass of orange juice.

A glucose level of 35 mg/dL (1.94 mmol/L) is considered significantly low (hypoglycemia), and the client's symptoms of diaphoresis indicate that the low glucose level is likely causing the symptoms. Providing the client with a glass of orange juice or another source of fast-acting carbohydrate is appropriate to quickly raise the blood sugar level and alleviate the symptoms of hypoglycemia.

Collecting a blood sample for hemoglobin A1c (HbA1c) is not necessary in this acute situation. HbA1c reflects the average blood glucose level over the past 2-3 months and is used to assess long-term glycemic control in clients with diabetes. It does not provide immediate information or guide immediate interventions for acute hypoglycemia.

Notifying the healthcare provider is not the first action to take in this situation. The client's low glucose level can be promptly addressed by administering a source of fast-acting carbohydrate, such as orange juice. If the client's symptoms persist or worsen despite appropriate intervention, or if there are other concerning factors, then notifying the healthcare provider would be appropriate.

Assessing the client for polyuria (excessive urination) and polyphagia (excessive hunger) is important in the overall management of diabetes, but it is not the immediate action to take in this acute situation of hypoglycemia. The priority at this time is to address the low blood sugar level and relieve the client's symptoms.

A. Genetically inherited disorders of family members. B. Frequency of laxative use for chronic constipation. C. Length and frequency of the client's tobacco use. D. Ingestion of shellfish or fish oil capsules daily.

Correct Answer is B

Explanation

A) Incorrect- Genetically inherited disorders of family members: While a family history of certain disorders might provide some insight, it is not typically the primary cause of elevated serum magnesium levels in an older adult.
B) Correct- Elevated serum magnesium levels are commonly associated with chronic laxative use, especially those containing magnesium-based compounds. Laxatives can lead to excessive magnesium intake, causing hypermagnesemia.
C. Incorrect- Smoking is not a common cause of elevated serum magnesium levels.

D. Incorrect- While dietary sources can contribute to magnesium intake, chronic laxative use is a more likely cause in this context.

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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

The practical nurse (PN) reports that a client who has a fingerstick glucose of 35 mg/dL (1.94 mmol/L) is alert and diaphoretic. Which action should the charge nurse take? Reference Ranges Glucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Correct Answer is B

Explanation

The nurse discovers that an older client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history?

Correct Answer is B

Explanation

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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.