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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Remaining silent does not necessarily indicate disapproval; it is a therapeutic communication technique to allow the client to express feelings without interruption.
Choice B rationale: While the client may be experiencing sadness, the nurse's silence is not reflecting the client's emotions but rather providing space for the client to express their thoughts and feelings.
Choice C rationale: Silence, in this context, is therapeutic because it allows the client time and space to reflect on and explore their own thoughts and feelings. It promotes self-discovery and expression.
Choice D rationale: Respecting the client's loss is a general principle, but the specific therapeutic use of silence in this situation is to allow the client to process and express their emotions.
Correct Answer is C
Explanation
Choice A rationale: Individual addiction counseling may be beneficial for the client but does not address the immediate physiological issue of Wernicke encephalopathy. Thiamine replacement is the priority.
Choice B rationale: Initiating disulfiram teaching is not relevant to the management of Wernicke encephalopathy. Disulfiram is used for alcohol aversion therapy, not thiamine deficiency.
Choice C rationale: Thiamine administration is the most critical intervention for Wernicke encephalopathy caused by alcohol addiction. Thiamine deficiency is a key factor in the development of this condition.
Choice D rationale: Nutrition referral may be important for the client's overall well being, but it is not the priority when the client is experiencing Wernicke encephalopathy. Immediate thiamine replacement is essential.
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