The nurse is providing care to a client having surgery to repair a retinal detachment to the left eye. Which intervention should the nurse implement during the postoperative period?

A) Correct- Viral meningitis is an inflammation of the meninges (the protective membranes surrounding the brain and spinal cord) caused by a viral infection. While it can be serious, it is generally less severe than bacterial meningitis. Monitoring the client's temperature is an important aspect of care, as changes in temperature can indicate the progression of the illness or the effectiveness of interventions. A temperature increase from 101°F to 102°F is a subtle change but may still require close monitoring and symptom management. The practical nurse (PN) is capable of monitoring vital signs, including temperature, and reporting any changes to the registered nurse (RN) or healthcare provider. It is within the PN's scope of practice to assess and report changes in vital signs and general condition. The other scenarios involve more complex clinical situations that may require the expertise of registered nurses.
B) Incorrect- Myxedema coma is a severe form of hypothyroidism and is considered a medical emergency. Managing and assessing a client with myxedema coma requires advanced assessment, critical thinking, and interventions that are typically within the scope of registered nurses.
C) Incorrect- Diabetic ketoacidosis (DKA) is a complex condition that requires frequent monitoring of blood glucose levels, electrolytes, vital signs, and assessment of the level of consciousness. The change in the Glasgow Coma Scale score indicates a neurological deterioration that requires immediate attention and intervention, making it suitable for a registered nurse.
D) Incorrect- A subdural hematoma is a serious neurological condition that requires close monitoring of vital signs and neurological status. The change in blood pressure indicates a potential change in intracranial pressure and should be managed by registered nurses with expertise in neurological care.

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.