A client who has been taking clozapine reports experiencing a sore throat and has a temperature of 101.9° F (38.8° C). Which action should the nurse take?

Encourage Increase Intake of oral fluids.

Obtain a specimen for a complete blood count.

Complete an Abnormal Involuntary Movement Scale (AIMS).

Administer a PRN dose of acetaminophen.

Answer and Explanation

The Correct Answer is B

Choice A rationale: Encouraging an increase in oral fluids is a general intervention but may not address the specific concern related to a sore throat and elevated temperature.

Clozapine requires monitoring for potential agranulocytosis, and an infection should be ruled out with a complete blood count (CBC).

Choice B rationale: Obtaining a specimen for a complete blood count (CBC) is crucial to assess for clozapine-induced agranulocytosis, a potentially life-threatening side effect. A sore throat and fever are red flags for possible infection.

Choice C rationale: Completing an Abnormal Involuntary Movement Scale (AIMS) is not relevant to the current situation. A sore throat and fever require immediate attention to rule out infection.

Choice D rationale: Administering a PRN dose of acetaminophen may help reduce fever, but the priority is to investigate the potential cause of the symptoms. Obtaining a CBC is essential.

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Correct Answer is D

Explanation

Choice A rationale: Headaches can be associated with various factors and are not specific to depression.

Choice B rationale: Back pain can have multiple causes and is not specific to depression. Choice C rationale: Dizziness may have various causes and is not specific to depression. Choice D rationale: Excessive tiredness (fatigue) is a common symptom of depression and often associated with the overall low energy levels experienced by individuals with depressive disorders.

A. Recommend that the client talk with a social worker today. B. Offer the client a safe place to relax before the Interview. C. Assure client of an interview with the healthcare provider today. D. Ask the client to describe the stalker and If It is frequent.

Correct Answer is B

Explanation

Choice A Rationale: While talking to a social worker could be beneficial, it may not address the client's immediate need for safety and comfort. Social work intervention is important, but the priority is to ensure the client feels secure in the current environment.
Choice B Rationale: Offering a safe place to relax is crucial as it addresses the client's immediate need for safety and security. Feeling safe can help reduce anxiety and allows the client to compose themselves before discussing their concerns in detail.
Choice C Rationale: Assuring an interview with the healthcare provider is important, but it does not prioritize the client's immediate emotional and psychological needs. The assurance of care is part of the overall treatment plan but is secondary to providing a safe environment.
Choice D Rationale: Asking the client to describe the stalker is part of the assessment process, but it is not the most important initial action. The client's immediate emotional state must be stabilized before any detailed information gathering can be effective.

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A client who has been taking clozapine reports experiencing a sore throat and has a temperature of 101.9° F (38.8° C). Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing an intake mental health assessment with a client who is seeking services for depression. The client reports feeling dizzy, excessively tired, experiencing headaches, and back pain. Which symptom should the nurse suspect is related to the client's feelings of depression?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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