Patient Data
History and Physical
What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.
Assist the client to the bathroom
Assess mental status regularly
Provide oral care at least twice a day
Screen for orthostatic hypotension
Monitor calcium levels
Have an opioid agonist at the bedside
Correct Answer : B,C,D
Choice A rationale:
Clonazepam is not typically associated with a significant risk of causing urinary retention or frequent bathroom needs. There's no immediate need for bathroom assistance related to clonazepam use.
Choice B rationale:
Clonazepam is a medication that affects the central nervous system and can influence mental status. Regular assessment helps monitor for any changes or adverse effects.
Choice C rationale:
Clonazepam is administered orally, and it's important to ensure the client's oral health and comfort, especially since dry mouth can be a side effect.
Choice D rationale:
Clonazepam can cause drowsiness and potential changes in blood pressure, which could lead to orthostatic hypotension. Screening for this condition helps ensure the client's safety when changing positions.
Choice E rationale:
Clonazepam does not typically affect calcium levels. Monitoring calcium levels is not a standard nursing intervention when starting clonazepam.
Choice F rationale:
Clonazepam is not an opioid, and it does not require having an opioid agonist at the bedside. This intervention is not relevant to clonazepam use.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Rationale:
While emotional expression and ventilation can be therapeutic, it may not be the most appropriate coping strategy for someone with depression who may already be overwhelmed by negative emotions. Ventilating emotions without a structured approach might not provide the desired relief and can even exacerbate feelings of distress.
Choice B Rationale:
This choice may not be suitable for someone with depression because it could lead to further neglect of their own needs and contribute to feelings of guilt or exhaustion.
Choice C Rationale:
While relaxation techniques can be helpful, reducing the effort to solve problems may not be the most effective strategy for individuals with depression. Avoidance of problems can perpetuate feelings of helplessness and hopelessness.
Choice D Rationale:
For a client with depression who is struggling with handling personal circumstances, focusing on small achievable tasks can be a helpful coping strategy. Breaking down larger problems into manageable steps can reduce feelings of overwhelm and gradually improve the client's sense of accomplishment and self-efficacy.
Correct Answer is B
Explanation
Choice A rationale:
Sweet potatoes are not typically high in oxalates and are generally considered safe to consume in moderation for individuals with calcium oxalate renal stones.
Choice B rationale:
Spinach is high in oxalates, which can contribute to the formation of calcium oxalate renal stones. Therefore, the client should be instructed to avoid spinach and foods high in oxalates.
Choice C rationale:
Bananas are generally low in oxalates and are not likely to be a significant contributor to the formation of calcium oxalate renal stones. They are safe for most individuals to consume.
Choice D rationale:
Fish is generally not high in oxalates and is not a major concern for individuals with calcium oxalate renal stones. However, it's essential to maintain an overall balanced diet and stay hydrated to prevent stone formation.
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