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

Assist the client to the bathroom.

Have an opioid agonist at the bedside.

Provide oral care at least twice a day.

Assess mental status regularly.

Monitor calcium levels.

Screen for orthostatic hypotension.

Answer and Explanation

Correct Answer : A,D,F

Choice A rationale

Assisting the client to the bathroom is appropriate as clonazepam can cause dizziness and unsteadiness, increasing the risk of falls.

Choice B rationale

Having an opioid agonist at the bedside is not necessary for a client starting clonazepam. Clonazepam is a benzodiazepine, not an opioid.

Choice C rationale

Providing oral care at least twice a day is generally good practice for all patients, but it’s not specifically related to clonazepam use.

Choice D rationale

Assessing mental status regularly is crucial as clonazepam can cause changes in mood and behavior.

Choice E rationale

Monitoring calcium levels is not typically required for a client starting clonazepam.

Choice F rationale

Screening for orthostatic hypotension is important as clonazepam can lower blood pressure, leading to dizziness and fainting when the client stands up.

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Correct Answer is B

Explanation

Choice A rationale

While placing a certified copy of the living will in the patient’s record is important, it is not the immediate next step. The living will should be acknowledged, but the healthcare provider needs to be informed immediately.

Choice B rationale

Informing the healthcare provider of the patient’s wishes is the most appropriate next step. The healthcare provider can then make decisions based on the patient’s expressed wishes.

Choice C rationale

Arranging a family meeting with the palliative care team may be beneficial, but it is not the immediate next step. The healthcare provider needs to be informed first.

Choice D rationale

Notifying the nursing staff of the patient’s do not resuscitate status is important, but it is not the immediate next step. The healthcare provider needs to be informed first.

A. Bone misalignment B. Decreased range of motion C. Left arm that is cool to touch D. Swelling at the site of injury E. Blood pressure of 136/90 mm Hg F. Intense pain reported by client G. Oxygen saturation 95% on room air

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

Explanation

A.Bone misalignment- The nurse’s notes mention that the collarbone appears out of alignment on the left side. This could indicate a fracture or dislocation and should be investigated further.

B.Decreased range of motion- The client reports an inability to move his left arm. This could be due to the pain or a result of the injury and should be investigated further.

C.Left arm that is cool to touch- Decreased temperature in a limb can indicate poor circulation, which could be a result of the injury. This should be investigated further.

D.Swelling at the site of injury- Swelling and bruising are present on the client’s shoulder. This is a common sign of injury and should be investigated further.

E.Blood pressure of 136/90 mm Hg- While this blood pressure is not extremely high, it is on the higher end of normal. Given the client’s age and the stress of the situation, it would be worth monitoring.

F.Intense pain reported by client- The client reports a pain rating of 10 on a 0 to 10 scale in the left arm. This level of pain is concerning and should be addressed.

G.Oxygen saturation 95% on room air- While an oxygen saturation of 95% is within the normal range, given the client’s recent trauma and reported nausea, it would be prudent to monitor this closely.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Exhibits The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.

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

Explanation

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