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

Answer and Explanation

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.

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Correct Answer is A

Explanation

a. "Focus on the feelings generated by the hallucinations and present reality." This approach validates the child's experience and feelings while gently orienting them to reality, which is a therapeutic communication technique.
b. "Ignore what they are saying, while attempting to discover the underlying cause." Ignoring the child’s statements can make them feel dismissed and could increase their distress. It is important to address their experience directly and compassionately.
c. "Present objective evidence that the voices are not real." Presenting objective evidence may not be effective as the child’s belief in the voices can be very strong, and this approach may lead to further agitation.
d. "Tell them to stop discussing the voices." This approach is dismissive and does not help the child manage their symptoms or feel understood. It is important to engage with the child’s experience constructively.

A. stop the client in the hall and tell them that they must pace in the day room instead. B. keep hands in pockets so as not to appear threatening. C. speak softly and calmly, D. offer the client a cup of coffee.

Correct Answer is C

Explanation

a. Stop the client in the hall and tell them that they must pace in the day room instead. This can be confrontational and might escalate the situation.
b. Keep hands in pockets so as not to appear threatening. While non-threatening body language is important, the focus should be on verbal communication.
c. Speak softly and calmly. De-escalation is key in such situations. A calm and non-threatening approach is essential to build rapport and assess the situation.
d. Offer the client a cup of coffee. Stimulants like caffeine might worsen anxiety.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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