A client is admitted to an inpatient psychiatric unit, and the antipsychotic medication clozapine is prescribed. Which intervention should the nurse include in this client’s plan of care?

Inform unlicensed assistive personnel (UAP) that the client will likely complain of a sore throat and fever.

Place the client in protective isolation for the first two weeks of treatment with this medication.

Offer this medication to the client with food to decrease the possibility of gastric upset.

Report findings from the client’s weekly white blood cell (WBC) counts to the healthcare provider.

Answer and Explanation

The Correct Answer is D

A.   While sore throat and fever can be potential side effects of clozapine, informing UAP is not a proactive intervention. Regular monitoring of white blood cell (WBC) counts is crucial for
detecting clozapine-induced agranulocytosis.
B.   Protective isolation is not a standard practice for clients taking clozapine. Monitoring for specific side effects, such as agranulocytosis, is more important.
C. Offering clozapine with food is not a priority intervention for managing potential side effects.
Monitoring and reporting WBC counts take precedence.
D.   Clozapine is associated with the risk of agranulocytosis. Regular monitoring of WBC counts is essential, and any findings outside the normal range should be promptly reported to the
healthcare provider.

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Correct Answer is C

Explanation

A. While sleep deprivation is a concern, the client's impulsive behavior poses a greater immediate risk, making "Risk for self-directed violence related to impulsive behavior" the priority.
B. Ineffective coping may be a contributing factor, but the risk of self-directed violence takes precedence as the primary concern.
C. The client's impulsive behavior increases the risk of self-directed violence, making it the most urgent nursing priority.
D. Imbalanced nutrition is a concern, but the immediate risk of self-directed violence requires more immediate attention.

A. Have you experienced recent stresses? B. What foods do you like to eat? C. Do you often feel sad? D. Have you experienced sleep changes?

Correct Answer is C

Explanation

A. Inquiring about recent stresses is relevant but may not specifically address the emotional state associated with depression.
B. Asking about food preferences is important for a comprehensive assessment but may not be the most direct question for assessing depression.
C. Inquiring about whether the client often feels sad is crucial for assessing the emotional aspect of depression.
D. While changes in sleep patterns are significant, the question about feeling sad directly addresses the emotional component of depression, which is important for a comprehensive assessment.

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A client is admitted to an inpatient psychiatric unit, and the antipsychotic medication clozapine is prescribed. Which intervention should the nurse include in this client’s plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client at the mental health center reports difficulty concentrating at work, feeling very tired during the day, and sleeping 4 to 5 hours at night. To further assess for depression, which question is most important for the nurse to ask?

Correct Answer is C

Explanation

Which interventions should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)

A client who is an alcoholic receives a prescription for disulfiram 500 mg PO daily. Which instruction should the nurse provide to this client?

A client with post-traumatic stress disorder (PTSD) is experiencing a dissociative disorder episode. The situation quickly escalates, and the client becomes physically aggressive. Which intervention should the nurse implement first?

An adolescent female with an eating disorder is admitted to the in-patient psychiatric unit. Which intervention should the nurse implement?

Which individual should the nurse consider at the highest risk for suicide?

An adolescent who is exhibiting a depressed affect receives a prescription for an antidepressant drug. While the client is taking the antidepressant, which comparison of the client’s behavior before and after taking the drug is most important for the nurse to obtain?