A client diagnosed with schizophrenia disorder is prescribed clozapine. Which symptoms, related to the side effects of this medication, should prompt a nurse to intervene immediately?
Akathisia and hypersalivation
Dry mouth and urinary retention
Akinesia and insomnia
Sore throat, fever, and malaise
The Correct Answer is D
a. Akathisia and hypersalivation. These side effects are uncomfortable but generally not immediately life-threatening.
b. Dry mouth and urinary retention. These side effects are concerning and should be monitored, but they do not typically require immediate intervention unless severe.
c. Akinesia and insomnia. While akinesia (lack of movement) and insomnia are significant, they are not immediately life-threatening symptoms.
d. Sore throat, fever, and malaise. This choice is correct because these symptoms could indicate agranulocytosis, a potentially life-threatening side effect of clozapine that requires immediate medical intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a. Administer the 6mg Benztropine orally with a full glass of water on an empty stomach: Benztropine is an anticholinergic medication used to manage the extrapyramidal side effects (EPS) of antipsychotics. However, it's important to consult the healthcare provider before administering any additional medications.
b. Ask the healthcare provider to increase the dose of Haloperidol to assist with the side effect: Increasing the dose of Haloperidol might worsen the tardive dyskinesia symptoms.
c. Hold the dose of Haloperidol and notify the healthcare provider. (Correct) Haloperidol is an antipsychotic medication with a known side effect of tardive dyskinesia, which manifests as involuntary facial and body movements. Stopping the medication and informing the provider is crucial to determine the best course of action, which might involve dose adjustment or switching medications
d. Explain to the client that the side effects should diminish in one to two weeks: Tardive dyskinesia can be a persistent side effect, and reassurance without addressing the medication is not helpful.
Correct Answer is D
Explanation
a. Leave the client alone: Leaving the client alone during a flashback could be dangerous.
b. Journaling: While journaling can be helpful for managing PTSD, it's not appropriate during a crisis situation.
c. Flumazenil: Flumazenil is used to reverse benzodiazepine overdose, not for PTSD flashbacks.
d. remain with the client and ensure safety: A PTSD flashback can be overwhelming and lead to self-harm or aggression. The nurse's priority is to ensure the client's safety and the safety of others.
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