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. Assessing the usual level of activity and average sleep pattern is relevant but does not directly address the observed symptoms related to speech and tongue movements.
B. Blood pressure assessment is important for overall health monitoring but is not the most immediate concern related to the observed speech and tongue abnormalities.
C. Assessing the fit of dentures is crucial in this context, as poorly fitted dentures could contribute to speech difficulties and tongue abnormalities.
D. Body weight assessment is important for overall health but is not the most immediate concern in this situation. Assessing denture fit addresses the observed speech and tongue abnormalities more directly.

A. Ask the client to describe the history of the injuries. B. Invite a colleague to document during the interview. C. Close the examination room door for privacy. D. Request hospital security to come to the department.

Correct Answer is C

Explanation

A. While obtaining the client's history is important, ensuring privacy is a priority to maintain confidentiality and facilitate open communication.
B. Inviting a colleague to document is not the immediate priority; privacy is crucial in the initial stages of the interview.
C. Closing the examination room door for privacy is the most appropriate action to create a confidential and secure environment for the client to discuss their injuries and provide a history.
D. Requesting hospital security is not necessary at this point, as the spouse pacing outside does not necessarily indicate a security threat.

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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

While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client’s tongue is “worming”. The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain?

Correct Answer is C

Explanation

The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?

Correct Answer is C

Explanation

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