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Answer and Explanation
Question 1: Report an Issue
Choice A:
Report Wrong Answer Correct - Clonazepam, a benzodiazepine,
can cause dizziness and orthostatic
History and Physical Nurses' hypotension (a sudden drop in blood
Notes pressure upon standing). Screening for
orthostatic hypotension helps ensure the
Exhibits
client's safety.
The nurse reviews the physician's
Choice B:
orders for clonazepam and gives
the medication as ordered. What Correct - Benzodiazepines like clonazepam
nursing interventions are can cause dry mouth as a side effect.
appropriate for the client starting Regular oral care helps prevent oral
clonazepam? Select all that apply. complications and maintains the client's
comfort.
A. Screen for orthostatic
hypotension 1% Most selected Choice C:
B. Provide oral care at least twice a Incorrect - Monitoring calcium levels is not
day 0% directly related to clonazepam use.
Clonazepam is a benzodiazepine
C. Monitor calcium levels 0%
medication used to treat anxiety and
D. Assess mental status regularly certain seizure disorders. It does not have a
0% direct impact on calcium levels in the
E. Assist the client to the bathroom body. Therefore, monitoring calcium levels
0% is not a relevant nursing intervention in the
context of clonazepam administration.
F. Have an opioid agonist at the
bedside 0% Choice D:
Correct - Clonazepam is a central nervous
system depressant and can affect
cognitive function, mood, and alertness.
Regular mental status assessments help
, monitor any changes in the client's
cognitive state.
Choice E:
Correct - Clonazepam can cause dizziness
and impaired coordination, increasing the
risk of falls. Assisting the client to the
bathroom promotes safety and prevents
accidents.
Choice F:
Incorrect - Having an opioid agonist at the
bedside is not a standard practice when
administering clonazepam. Opioid
agonists are medications used to manage
pain and are not directly related to the
administration or effects of clonazepam,
which is a benzodiazepine used for anxiety
and seizures.
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Stella: i really gained from the review. It is so educating and knowledgeable. I
appreciate naxlex for the provision of the package ~ 4w ago
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Answer and Explanation
Question 2: Report an Issue
Choice A:
Report Wrong Answer Incorrect - Phototherapy, often used to
treat conditions like seasonal affective
History and Physical Nurses' disorder (SAD) or certain skin conditions,
Notes involves exposure to specific wavelengths
of light. It is not typically used as a
treatment for distressing thoughts and
,The client is in the hospital after her memories related to trauma, as described
house collapsed during a in the client's situation.
hurricane. She has been in the
Choice B:
intensive care unit for 2 weeks and
moved today to the surgical floor Incorrect - Lithium is primarily used to treat
to continue monitoring her bipolar disorder and is not a first-line
respiratory function and to treatment for trauma-related symptoms
complete intravenous antibiotic or acute stress disorder. The client's
administration. symptoms are more indicative of trauma-
related distress, which would be addressed
0900
through psychotherapeutic approaches
Pain assessment completed. The like cognitive behavioral therapy (CBT).
client's pain is 2/10. The client
Choice C:
requests sleeping medication for
the night. She states that she has Incorrect - "Consciousness-raising" is not a
horrible thoughts and memories recognized treatment intervention in this
about the house collapsing all the context.It's important to focus on
time and that it is keeping her from evidence-based therapeutic approaches
falling asleep. She states, "I used to for trauma-related symptoms, such as
be so happy before psychotherapy and support services.
all of this happened. Now I can't Choice D:
seem to get out of this funk I am in." Correct - Cognitive behavioral therapy
The client would also prefer to be in (CBT) is Given the client's distressing
a quieter area of the unit as she is thoughts and memories, CBT is a highly
currently by the nurses' station and effective psychotherapy approach. It
hears talking and alarms focuses on identifying and modifying
constantly. negative thought patterns and behaviors
1100 associated with trauma. CBT can help the
client develop healthier coping strategies.
Noted that the client is using
fantasy, isolation, and suppression Choice E:
as defense mechanisms. Notified Correct - Animal-assisted therapy involves
the. Start clonazepam 0.25 mg PO interacting with trained animals to improve
every 12 hours emotional well-being. Since the client
The client is in the hospital after her expresses feeling unhappy and having
house collapsed during a difficulty coping, animal therapy can
hurricane. She has been in the provide comfort, reduce stress, and
intensive care unit for 2 weeks and promote a sense of companionship.
moved today to the surgical floor Choice F:
to continue monitoring her
respiratory function and to Incorrect - Electroconvulsive therapy (ECT)
complete intravenous antibiotic is a treatment primarily used for severe
administration. cases of depression or certain psychiatric
conditions that are unresponsive to other
Patient Data treatments. It involves inducing controlled
seizures to affect brain chemistry. ECT is
, What other treatments might be not a first-line treatment for the client's
helpful for this client? Select all that distressing thoughts and memories
apply. following a traumatic event.
A. Phototherapy 0%
B. Administration of lithium 0%
C. Consciousness-raising 0%
D. Cognitive behavioral therapy 1%
Most selected
E. Animal therapy 0%
F. Electroconvulsive therapy 0%
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Answer and Explanation
Question 3: Report an Issue
Choice A:
Report Wrong Answer Correct - Demonstrating the technique
used to monitor blood glucose levels is
A client with a history of type 1 crucial.Incorrect technique can lead to
diabetes mellitus (DM) and asthma inaccurate readings, impacting insulin
is readmitted to the unit for the dosing decisions and blood sugar control.
third time in two months with a
Choice B:
current fasting blood sugar (FBS) is
325 mg/dL (18 mmol/L). The client Correct - Some asthma medications, like
describes to the nurse of not corticosteroids, can elevate blood glucose
understanding why the blood levels.Evaluating the client's asthma
glucose level continues to be out of medications is essential as they can
control. Which intervention(s) contribute to fluctuations in blood sugar
should the nurse implement? levels.
(Select all that apply.)
Choice C:
Reference Range
Incorrect- Asking the client if they want a
Blood Glucose [74 to 106 mg/dL (4.1 different manufacturer's glucose
to 5.9 mmol/L)] monitoring device is not helpful, because it
does not address the underlying causes of
A. Have the client demonstrate
the poor glycemic control. The client may
technique used to monitor blood
also perceive this as a lack of confidence