Following morning care, a client with a C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implementfirst?

Administer a prescribed PRN dose of hydralazine.

Assess the client's blood pressures every 15 minutes.

Teach the client to recognize the symptoms of dysreflexia.

Relieve any kinks or obstruction in the client's Foley tubing.

Answer and Explanation

The Correct Answer is D

A)   This can be done if initial non-pharmacological interventions do not relieve symptoms, but it is not the first step.
B)   Monitoring blood pressure is important, but it is secondary to removing the stimulus causing the dysreflexia.
C)   Incorrect- While education is important for long-term management, the client is currently experiencing symptoms that need immediate attention. The priority is to assess and address the current symptoms.
D)   The client is likely experiencing autonomic dysreflexia, characterized by a sudden and severe increase in blood pressure, flushing, headache, and other symptoms triggered by a noxious stimulus below the level of injury. The first step in managing autonomic dysreflexia is to identify and eliminate the triggering stimulus. For clients with a Foley catheter, a common cause of autonomic dysreflexia is bladder distention due to a kinked or obstructed catheter. Relieving any kinks or obstructions in the Foley tubing can immediately alleviate the symptoms.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","B","D","E"]

Explanation

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.

A. Explain to the UAP that changes in a client's condition should be reported immediately. B. Advise the UAP to stop providing care so the nurse can assess the client's condition. C C. Ask the UAP to position the client so the oral medications can be administered. D. Determine why the UAP did not notify the nurse of the change in the client's condition.

Correct Answer is B

Explanation

A) Incorrect- While it's important for UAPs to report changes in a client's condition, the immediate priority is to assess and address the deteriorating condition of the client. The nurse's first action should be to stop the current care being provided and assess the client.
B) Correct- In this situation, the priority is to ensure the safety and well-being of the client. The client's deteriorated condition needs to be assessed promptly by a licensed nurse to determine the appropriate interventions. Stopping the care being provided by the unlicensed assistive personnel (UAP) allows the nurse to focus on the client's immediate needs.
C) Incorrect- Administering oral medications is not the immediate priority in this situation. The client's deteriorating condition takes precedence over administering medications.
D) Incorrect- While investigating the situation and addressing communication gaps is important, the first priority is to assess and address the client's current condition. The nurse needs to take immediate action to ensure the client's safety and well-being.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Following morning care, a client with a C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implementfirst?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse reviews the physician's orders for clonazepam and gives the medication as ordered. What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

Nursing Interventions for Client Starting Clonazepam:

Correct Answer is B

Explanation

A client with cancer is admitted to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client's admission prescriptions include radiation therapy. Which action should the nurse implement?

A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother because he has a fever and an earache. During the assessment, the mother asks the nurse why her child is at the 5th percentile for weight and height for his age. Which response is best for the nurse to provide?

A client who weighs 110 pounds receives a prescription for dalteparin 150 units/kg subcutaneously daily for 4 months. The medication is available in 7,500 units/0.3 mL prefilled syringe. How many mL should the nurse administer? (Enter numerical value only.)

A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "Kill, kill." Which question should the nurse ask the client next?

The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome Indicates that the program was effective?

An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client's compliance with self-care?