A client diagnosed with Illness Anxiety Disorder is prescribed clonazepam for underlying anxiety. Of the following, which is of utmost importance when caring for this client?

Administer the medication with food.

Administer the medication to the client at night to avoid daytime sedation.

Encourage the client to avoid drinking alcohol when taking this medication.

Assess for history of smoking.

Answer and Explanation

The Correct Answer is C

Choice A Reason:

Administer the medication with food.

Administering clonazepam with food can help reduce gastrointestinal discomfort, but it is not the most critical consideration. While it is beneficial to minimize potential side effects like nausea, it does not address the primary safety concerns associated with clonazepam use.

Choice B Reason:

Administer the medication to the client at night to avoid daytime sedation.

Administering clonazepam at night can help avoid daytime sedation, which is a common side effect of benzodiazepines. However, this is not the most critical safety concern. While managing sedation is important, it does not address the potential for more serious interactions and risks.

Choice C Reason:

Encourage the client to avoid drinking alcohol when taking this medication.

This is the correct response. Alcohol can significantly increase the sedative effects of clonazepam, leading to dangerous levels of sedation, respiratory depression, and even death. It is crucial to educate clients about the risks of combining alcohol with benzodiazepines to prevent potentially life-threatening interactions.

Choice D Reason:

Assess for history of smoking.

While assessing for a history of smoking is part of a comprehensive health assessment, it is not the most critical consideration when administering clonazepam. Smoking does not have the same immediate and severe interaction risks with clonazepam as alcohol does.

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

Explanation

Choice A Reason:

The statement “Documentation of the event will include interventions attempted prior to initiating restraints” is correct. Proper documentation is crucial when restraints are used. This includes detailing the client’s behavior that necessitated the restraint, the interventions attempted before applying the restraint, the type of restraint used, and the time it was applied. This documentation ensures transparency and accountability, and it helps in evaluating the necessity and appropriateness of the restraint use.

Choice B Reason:

The statement “The physician must be present at the time of the restraint episode” is incorrect. While a physician’s order is required for the use of restraints, the physician does not need to be physically present at the time of the restraint episode. However, the physician must evaluate the client within a specified time frame after the restraint is applied, typically within one hour. This ensures that the restraint is medically justified and that the client’s condition is appropriately monitored.

Choice C Reason:

The statement “The client will be turned every 2 hours” is correct. Clients in restraints must be regularly repositioned to prevent complications such as pressure ulcers and to ensure their comfort. Turning the client every 2 hours is a standard practice to maintain skin integrity and promote circulation. This intervention is part of the comprehensive care plan for clients in restraints.

Choice D Reason:

The statement “The client will need to be monitored every one-half hour” is correct. Frequent monitoring of clients in restraints is essential to ensure their safety and well-being. This includes checking for signs of distress, ensuring that the restraints are not causing harm, and assessing the client’s vital signs5. Monitoring every 30 minutes helps in promptly addressing any issues that may arise and ensures that the restraints are used safely and effectively.

Correct Answer is ["125"]

Explanation

To calculate the infusion rate in drops per minute:

Identify the total volume to be infused: 125 mL
Identify the total time for infusion: 1 hour (which is 60 minutes)
Identify the drop factor: 60 gtts/mL

Step 1: Calculate the infusion rate in mL per minute.

Volume (mL) ÷ Time (minutes)
125 mL ÷ 60 minutes = 2.0833 mL per minute

Step 2: Calculate the infusion rate in drops per minute.

Infusion rate (mL per minute) × Drop factor (gtts/mL)
2.0833 mL per minute × 60 gtts/mL = 125 gtts per minute

The drug will infuse at 125 drops per minute.

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A client diagnosed with Illness Anxiety Disorder is prescribed clonazepam for underlying anxiety. Of the following, which is of utmost importance when caring for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When placing an agitated client in restraints, the nurse understands that which of the following must occur?

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

Explanation

An IV infusion of 125 mL of a GI prokinetic agent is ordered to be given over 1 hour. The nurse will use a microdrip infusion set (60 gtts/mL). How many drops per minute will the drug infuse at the proper rate? Use a preceding zero if necessary. Do not use trailing zeros.

Correct Answer is ["125"]

Explanation

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