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.
A.
Screen for orthostatic hypotension
B.
Provide oral care at least twice a day
C.
Monitor calcium levels
D.
Assess mental status regularly
E.
Assist the client to the bathroom
F.
Have an opioid agonist at the bedside
The Correct Answer and Explanation is:
The correct answers are A. Screen for orthostatic hypotension, D. Assess mental status regularly, and E. Assist the client to the bathroom.
Explanation:
Clonazepam is a benzodiazepine primarily used to treat anxiety, panic disorders, and seizures. It works by enhancing the activity of GABA (gamma-aminobutyric acid), a neurotransmitter that calms nervous system activity. Starting clonazepam requires careful nursing interventions to prevent adverse effects and ensure the patient’s safety.
- A. Screen for orthostatic hypotension: Orthostatic hypotension, or a sudden drop in blood pressure when moving from sitting or lying down to standing, is a potential side effect of clonazepam. Benzodiazepines like clonazepam can cause dizziness and hypotension due to their central nervous system depressant effects. Screening for orthostatic hypotension is important to avoid falls or fainting episodes, especially in older clients who are at higher risk.
- D. Assess mental status regularly: Clonazepam can cause sedation, drowsiness, confusion, and impaired cognition. It is critical to monitor the client’s mental status regularly to detect any signs of excessive sedation, memory impairment, or paradoxical reactions like increased agitation or irritability. Changes in mental status could indicate the need for dose adjustments or discontinuation.
- E. Assist the client to the bathroom: Due to the sedative effects of clonazepam, clients may experience dizziness, drowsiness, or unsteady gait, increasing their risk of falls. Assisting the client when ambulating, especially when going to the bathroom, helps reduce fall risk and promotes client safety.
Incorrect Options:
- B. Provide oral care at least twice a day: While oral care is important for overall health, it is not a specific intervention required for clients taking clonazepam.
- C. Monitor calcium levels: Clonazepam does not affect calcium metabolism or levels, so this intervention is not necessary.
- F. Have an opioid agonist at the bedside: Clonazepam is not an opioid, and opioid antagonists like naloxone are not required for its use.
These interventions aim to minimize risks and promote safe medication use, particularly in vulnerable populations such as the elderly.