In caring for a client following a head injury, the nurse plans to assess for rhinorrhea so that a sample can be tested for the presence of cerebrospinal fluid (CSF). At which location should the nurse observe for this finding?

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A. Clonazepam is a benzodiazepine used primarily for anxiety disorders and can affect mental status, including cognition and level of alertness. Regular assessment helps monitor for any changes in mental status, such as drowsiness, confusion, or sedation, which are potential side effects of clonazepam.
B. This intervention helps maintain oral hygiene, which is important when a client is taking medications orally. Benzodiazepines like clonazepam can cause dry mouth as a side effect, which can contribute to oral hygiene issues such as increased risk of dental caries or oral infections.
C. Clonazepam itself does not directly affect calcium levels. Monitoring calcium levels is not a routine nursing intervention specifically related to clonazepam administration. This option is not appropriate in this context.
D. Clonazepam is not an opioid and does not directly interact with opioids in a way that would necessitate having an opioid agonist at the bedside. This option is not relevant for a client starting clonazepam.
E. Clonazepam can cause dizziness and impair coordination, especially when starting the medication or with dose changes. Assisting the client to the bathroom helps prevent falls and ensures safety, particularly if the client experiences dizziness or sedation.
F. Benzodiazepines like clonazepam can cause hypotension (low blood pressure), which may exacerbate upon standing (orthostatic hypotension). Screening involves checking blood pressure and heart rate in different positions (lying, sitting, standing) to detect orthostatic changes. This is important to prevent falls and other complications.

Rationale

A. A. lung biopsy involves obtaining a tissue sample from the lung for microscopic examination. It is typically performed to diagnose conditions such as lung cancer or to investigate unusual findings seen on imaging studies. However, for a client with COPD experiencing increased shortness of breath, a lung biopsy is not typically indicated as a first-line investigation. It is more invasive and usually reserved for specific diagnostic purposes other than routine evaluation of COPD symptoms.

B. Antibody testing is used to detect antibodies specific to certain infections or autoimmune conditions. It is not typically used in the routine evaluation of COPD symptoms unless there is suspicion of a specific autoimmune or infectious cause contributing to exacerbations, which is less common in COPD compared to other conditions.

C. A. sweat test is used to diagnose cystic fibrosis (CF), a genetic disorder that affects the lungs and digestive system. It measures the amount of chloride in sweat, which is elevated in individuals with CF. Since COPD and CF are distinct conditions with different underlying causes and diagnostic criteria, a sweat test is not appropriate for evaluating COPD symptoms.

D. Spirometry is the most appropriate test to schedule for evaluating a client with COPD who reports increased shortness of breath with activity. Spirometry measures lung function by assessing how much and how quickly a person can move air into and out of their lungs. It provides valuable information about the severity of airflow limitation, which is characteristic of COPD.