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 B

Explanation

Choice A rationale:
Cocaine is a stimulant and typically leads to increased heart rate (tachycardia) and respiratory rate (tachypnea). Bradycardia (slow heart rate) and bradypnea (slow respiratory rate) would be atypical findings with cocaine use.

Choice B rationale:
Cocaine is a stimulant drug that typically produces effects such as increased heart rate, increased blood pressure, stimulation, euphoria, and dilated pupils. These physiological and psychological effects are common when someone has used cocaine.

Choice C rationale:
While cocaine use can cause hallucinations and paranoia during intoxication or withdrawal, these symptoms are not typically the primary manifestations. The most common initial effects are stimulation and increased alertness.
Hallucinations and delusions may occur with substance use, but they are not the most expected or specific findings for cocaine use.

Choice D rationale:
Cocaine use is associated with increased energy, euphoria, and heightened arousal. Lethargy and depression are more likely during the comedown phase or withdrawal from cocaine, rather than immediately after use.

A. Five-pound (2.3 kg) weight gain. B. Nausea and vomiting. C. Short-term memory loss. D. Depressed affect.

Correct Answer is B

Explanation

Choice A rationale:
A five-pound weight gain in a client taking lithium carbonate is significant. however, the timeframe of the weightgain is to be known.Choice B rationale:
Nausea and vomiting are known side effects of lithium that should be reported as they can cause electrolyte imbalance.

Choice C rationale:
Short-term memory loss is a potential side effect of lithium, but it may not require immediate reporting unless it significantly affects the client's daily functioning or is associated with other concerning symptoms.

Choice D rationale:
A depressed affect is a symptom that should be addressed as part of the client's ongoing psychiatric care, but it may not warrant immediate reporting unless it is severe and requires a change in the treatment plan. The priority in this case is the potential lithium toxicity indicated by the weight gain.

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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

The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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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.