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 B

Explanation

A. Sitting in the chair next to the client may be a supportive action but does not address the immediate concern of the client's behavior.
B. Listening to what the client is saying is crucial to understand the content and nature of the auditory hallucinations, which can guide further interventions.
C. Escorting the client to his room may be necessary if the behavior poses a risk, but understanding the content of the hallucinations should precede immediate removal.
D. Administering a PRN sedative may be considered later based on the assessment, but understanding the nature of the hallucinations and the client's current state is the priority.

A. Helping clients identify areas of problem in their lives. B. Discussing ways to use new coping skills learned. C. Establishing a rapport with group members. D. Clarifying the nurse’s role and clients’ responsibilities.

Correct Answer is B

Explanation

A. Helping clients identify areas of problem in their lives is more characteristic of the orientation phase of group development, where the group establishes trust and defines the purpose and goals.
B. Discussing ways to use new coping skills learned is appropriate during the working phase.
This phase focuses on problem-solving, decision-making, and achieving the goals identified in the orientation phase.
C. Establishing a rapport with group members is crucial during the orientation phase to build trust and create a safe environment for group members to share their experiences.
D. Clarifying the nurse’s role and clients’ responsibilities is more relevant in the orientation phase as the group establishes structure and guidelines.

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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

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Correct Answer is B

Explanation

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