Patient Data

History and Physical

Exhibits here

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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:
It is crucial to obtain information about any history of heart disease before starting an antidepressant-like sertraline because certain antidepressants can have effects on the heart's electrical conduction system. Sertraline, in particular, may be associated with QT interval prolongation, and individuals with a history of heart disease may be at higher risk. Assessing this history helps the nurse make informed decisions about the client's treatment and potential risks.

Choice B rationale:
While a familial history of mental illness is important to consider, it is not the most critical information to obtain before starting sertraline. The primary concern with sertraline is its potential impact on the heart's electrical conduction system, making option A (heart disease history) more relevant.

Choice C rationale:
Current weight is essential to monitor during treatment with sertraline as it can impact dosing, but it is not the most critical piece of information to obtain before starting the medication.

Choice D rationale:
Medication history is important but not the most critical information in this context. Assessing any history of heart disease (Option A) takes precedence due to the specific cardiovascular risks associated with sertraline.

A. Denies cramps, weakness, or nausea B. BP 116/68 mm Hg, HR 75 bpm C. Potassium level 3.6 mEq/L (3.6 mmol/L) D. Verbalizes commitment to dialysis appointments E. Client states that she will need to resume her Lisinopril to control blood pressure F. The client is eager to add dark green vegetables and potatoes to her diet

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

Explanation

Choice A rationale:
This finding suggests that the client may not be fully disclosing her symptoms or may not be aware of their significance. It should be investigated further.

Choice B rationale:
The blood pressure and heart rate are within an acceptable range, indicating that the client's blood pressure is relatively stable.

Choice C rationale:
A potassium level of 3.6 mEq/L falls within the reference range, indicating that the client's potassium level is within normal limits.

Choice D rationale:
The client's commitment to attending dialysis appointments is a positive sign, as regular dialysis is crucial for managing end-stage renal disease.

Choice E rationale:
If the client recognizes the need to resume her Lisinopril for blood pressure control, it indicates her understanding of the medication's importance in managing her hypertension.

Choice F rationale:
The client's willingness to incorporate nutrient-rich foods like dark green vegetables and potatoes into her diet is a positive sign for improving her nutritional status, which can be beneficial for her overall health. However, dietary changes should be discussed with her healthcare provider to ensure they are appropriate for her condition.

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Patient Data History and Physical Exhibits here What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?

Correct Answer is A

Explanation

Patient Data Exhibits The client has been in IMU unit for 3 days and the physician plans to discharge her home today. Select the client actions that were effective in her treatment.

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

Explanation

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

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The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?

The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Patient Data History and Physical Exhibits here What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.

Patient Data

History and Physical

Exhibits here

What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.