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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.

Nursing Test Bank

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

Explanation

A) Incorrect- Standard precautions are used for all clients to prevent the spread of infections.
However, in the case of MRSA, contact precautions are needed due to the risk of direct transmission through physical contact.
B) Correct- Monitoring the white blood cell count is important to assess for signs of infection, as an elevated count might indicate an ongoing inflammatory response.
C) Correct- Foul-smelling drainage from an incision with suspected MRSA indicates a potential infection. Contact precautions are appropriate for MRSA, which include wearing gloves and gowns when entering the client's room to prevent the spread of the bacteria.
D) Correct- Sending wound drainage for culture and sensitivity helps identify the specific microorganisms causing the infection and guides appropriate antibiotic treatment.
E) Incorrect- A low-bacteria diet is not relevant to the situation. MRSA is caused by a bacterium, not by dietary factors. The focus should be on infection control measures and appropriate medical interventions.

A. Anxiety as evidenced by abdominal complaints secondary to depression. B. Imbalanced nutrition as evidenced by 25 pound (11 kg) weight loss in four months. C. Chronic low self-esteem as evidenced by feelings of worthlessness. D. Risk for self-directed violence as evidenced by feelings of hopelessness.

Correct Answer is D

Explanation

The client's statement of feeling worthless most days and having no interest in activities she previously enjoyed indicates a potential risk for self-directed violence, including self-harm or suicidal ideation. These signs are significant and require immediate attention and intervention by the nurse.

Assessing and addressing the client's risk for self-directed violence is of utmost importance to ensure her safety and well-being. The nurse should initiate a thorough assessment of the client's mental health, including assessing for any suicidal ideation, intent, or plans. It is crucial to establish a supportive and non-judgmental environment for the client to express her feelings and concerns.

The nurse should collaborate with the healthcare team to develop an appropriate care plan that may involve interventions such as close observation, involving a mental health professional, implementing safety measures, and providing emotional support.

While addressing other nursing problems, such as anxiety, imbalanced nutrition, and chronic low self-esteem, is important, the immediate concern is the client's risk for self-directed violence due to her feelings of hopelessness.

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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

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care? (Select all that apply.)

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

Explanation

Correct Answer is D

Explanation

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The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behavior(s) indicate the client understands how to maintain balance safely? (Select all that apply.)

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.