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","B","C"]

Explanation

The assessment findings that require immediate follow-up by the nurse are: muscle cramps, tingling sensation in arms and legs, and lightheadedness.

These are signs of electrolyte imbalance, which can be caused by missed dialysis sessions, dehydration, or infection. Electrolyte imbalance can lead to serious complications such as cardiac arrhythmias, seizures, or coma.

The nurse should monitor the client's vital signs, neurological status, and cardiac rhythm, and notify the physician for further orders. The nurse should also assess the client's fluid status, hydration, and nutritional intake, and provide education on the importance of adhering to the dialysis schedule and dietary restrictions.

A. Any history of heart disease. B. Familial history of mental illness. C. Current weight. D. Medication history.

Correct Answer is D

Explanation

A. Any history of heart disease: While a history of heart disease is important for general health, it is not the most critical factor prior to initiating sertraline. The nurse should still assess for cardiovascular conditions, but this is not the most pressing concern.

B. Familial history of mental illness: While a familial history of mental illness can inform treatment decisions, it is not the most immediate or critical piece of information before starting sertraline.

C. Current weight: Weight is generally not the primary consideration before starting sertraline. However, weight changes can occur during treatment, but this is more of a concern during the ongoing management of the medication.

D. Medication history: Sertraline, as a selective serotonin reuptake inhibitor (SSRI), can interact with other medications, especially those affecting serotonin levels (e.g., other antidepressants, MAO inhibitors, etc.). It is crucial to assess the client’s current medication history to prevent harmful drug interactions, such as serotonin syndrome. This is the most important information to gather before initiating treatment.

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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

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

Explanation

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

Correct Answer is D

Explanation

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?

The nurse is developing a plan of care for an older client with hypertension who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?

The mother of an 8-month-old infant with profound mental and physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth and development milestones. How should the nurse respond to this mother?

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

Patient Data

History and Physical

Exhibits here

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